Healthcare Provider Details

I. General information

NPI: 1710246921
Provider Name (Legal Business Name): LIFE GATEWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2128 PINK CORAL DR
NORTH LAS VEGAS NV
89031-0985
US

IV. Provider business mailing address

3605 MOUNTAIN CREST ST
LAS VEGAS NV
89129-7864
US

V. Phone/Fax

Practice location:
  • Phone: 702-234-9822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNV

VIII. Authorized Official

Name: CYNTHIA EWELL
Title or Position: MANAGING MEMBER
Credential:
Phone: 702-752-9274