MEDICARE: LAURA ELIZABETH MALSTROM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1952695363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA ELIZABETH MALSTROM

Provider Business Mailing Address
First Line	:	5410 LA PALOMAS CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-1916
Country	:	US
Telephone Number	:	702-370-7477
Fax Number	:	702-269-0522

Provider Business Practice Location Address
First Line	:	5410 LA PALOMAS CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-1916
Country	:	US
Telephone Number	:	702-370-7477
Fax Number	:	702-269-0522

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2011
Last Update Date	:	06/02/2011

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