Healthcare Provider Details

I. General information

NPI: 1699386250
Provider Name (Legal Business Name): JEREMY JOSEPH URCIOLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 SPENCER ST
LAS VEGAS NV
89119-9303
US

IV. Provider business mailing address

503 CALYPSO DR
HENDERSON NV
89002-9618
US

V. Phone/Fax

Practice location:
  • Phone: 702-799-9710
  • Fax:
Mailing address:
  • Phone: 170-230-0839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCI2951
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: