Healthcare Provider Details

I. General information

NPI: 1740602366
Provider Name (Legal Business Name): INGRID GARDELIN-ENGLUND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 SPENCER ST #118
LAS VEGAS NV
89119-9303
US

IV. Provider business mailing address

4055 SPENCER ST #118
LAS VEGAS NV
89119-9303
US

V. Phone/Fax

Practice location:
  • Phone: 702-799-9710
  • Fax: 702-799-9712
Mailing address:
  • Phone: 702-799-9710
  • Fax: 702-799-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: