Healthcare Provider Details

I. General information

NPI: 1649414327
Provider Name (Legal Business Name): RICHARD ANTHONY GRECO PES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 LAKE TAHOE BLVD
SOUTH LAKE TAHOE CA
96150-6305
US

IV. Provider business mailing address

1900 LAKE TAHOE BLVD
SOUTH LAKE TAHOE CA
96150-6305
US

V. Phone/Fax

Practice location:
  • Phone: 530-573-3251
  • Fax: 530-542-7041
Mailing address:
  • Phone: 530-573-3251
  • Fax: 530-542-7041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0000
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: