MEDICARE: DIVINE FAMILY ASSISTANCE OF NEVADA

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	103TB0200X	Cognitive & Behavioral Psychologist

General Provider Information

NPI Number	:	1972833721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE FAMILY ASSISTANCE OF NEVADA

Provider Business Mailing Address
First Line	:	9021 VICTOR CREEK AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-3274
Country	:	US
Telephone Number	:	702-348-7653
Fax Number	:

Provider Business Practice Location Address
First Line	:	9021 VICTOR CREEK AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-3274
Country	:	US
Telephone Number	:	702-348-7653
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	VALESIA COOK
Credential	:
Telephone Number	:	702-348-7653

Provider Enumeration Date	:	12/29/2009
Last Update Date	:	12/29/2009

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