Healthcare Provider Details

I. General information

NPI: 1770984395
Provider Name (Legal Business Name): DEIDRE CHARGUALAF MS, MFCT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 E PATRICK LN STE 2
LAS VEGAS NV
89120-3479
US

IV. Provider business mailing address

7600 S JONES BLVD APT. 2038
LAS VEGAS NV
89139-0551
US

V. Phone/Fax

Practice location:
  • Phone: 702-677-1267
  • Fax:
Mailing address:
  • Phone: 702-379-1682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: