Healthcare Provider Details

I. General information

NPI: 1114233004
Provider Name (Legal Business Name): LOUIS A PAGANO JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST ATTN: 21 MDS/SGOW-MENTAL HEALTH
PETERSON AFB CO
80914-1540
US

IV. Provider business mailing address

559 VINCENT ST ATTN: 21 MDS/SGOW-MENTAL HEALTH
PETERSON AFB CO
80914-1540
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-8873
  • Fax:
Mailing address:
  • Phone: 719-526-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number590
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: