MEDICARE: CHRISTINE M. FORMICA

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	1041C0700X	Clinical Social Worker	5789-C	NV
2	253J00000X	Foster Care Agency	5789-C	NV

General Provider Information

NPI Number	:	1962717892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTINE M. FORMICA

Provider Business Mailing Address
First Line	:	2152 JASPER BLUFF ST UNIT 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5977
Country	:	US
Telephone Number	:	702-327-2829
Fax Number	:

Provider Business Practice Location Address
First Line	:	2152 JASPER BLUFF ST UNIT 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5977
Country	:	US
Telephone Number	:	702-327-2829
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. CHRISTINE MICHELLE FORMICA
Credential	:	MSW
Telephone Number	:	702-327-2829

Provider Enumeration Date	:	08/16/2010
Last Update Date	:	08/16/2010

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