Healthcare Provider Details

I. General information

NPI: 1093241549
Provider Name (Legal Business Name): MICHAEL MAZZONE BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 N RANCHO DR STE 113
LAS VEGAS NV
89130-3188
US

IV. Provider business mailing address

3660 N RANCHO DR STE 113
LAS VEGAS NV
89130-3188
US

V. Phone/Fax

Practice location:
  • Phone: 702-209-3544
  • Fax: 725-205-3800
Mailing address:
  • Phone: 702-209-3544
  • Fax: 725-205-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-24661
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: