Healthcare Provider Details

I. General information

NPI: 1689174732
Provider Name (Legal Business Name): GLADYS MICHELLE MAZARIEGOS MS, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9089 S PECOS RD STE 3400
HENDERSON NV
89074-7184
US

IV. Provider business mailing address

9089 S PECOS RD STE 3400
HENDERSON NV
89074-7184
US

V. Phone/Fax

Practice location:
  • Phone: 702-867-5810
  • Fax: 702-867-5811
Mailing address:
  • Phone: 702-867-5810
  • Fax: 702-867-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-46871
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: