Healthcare Provider Details

I. General information

NPI: 1003127499
Provider Name (Legal Business Name): MARYSOL REZANOV LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARYSOL AMEZCUA LCSW

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4170 S DECATUR BLVD STE C1
LAS VEGAS NV
89103-5863
US

IV. Provider business mailing address

4170 S DECATUR BLVD STE C1
LAS VEGAS NV
89103-5863
US

V. Phone/Fax

Practice location:
  • Phone: 702-659-8827
  • Fax: 702-852-0984
Mailing address:
  • Phone: 702-659-8827
  • Fax: 702-852-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6215-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: