Healthcare Provider Details

I. General information

NPI: 1215458039
Provider Name (Legal Business Name): GREG JORGE PAGELA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 E LAKE MEAD BLVD
NORTH LAS VEGAS NV
89030-6514
US

IV. Provider business mailing address

2820 E LAKE MEAD BLVD
NORTH LAS VEGAS NV
89030-6514
US

V. Phone/Fax

Practice location:
  • Phone: 702-749-8500
  • Fax: 702-749-8509
Mailing address:
  • Phone: 702-749-8500
  • Fax: 702-749-8509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1356P-S
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: