Healthcare Provider Details

I. General information

NPI: 1821384009
Provider Name (Legal Business Name): DISA ESPIRITU LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2533 LA FORTUNA AVE
LAS VEGAS NV
89121-5436
US

IV. Provider business mailing address

PO BOX
HONOLULU HI
96828
US

V. Phone/Fax

Practice location:
  • Phone: 702-354-5996
  • Fax:
Mailing address:
  • Phone: 702-354-5996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-4473
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: