MEDICARE: MRS. ALBA GRACIELA PUENTES AGUSTIN LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	106854	CA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	106H00000X	Marriage & Family Therapist	2557	NV

General Provider Information

NPI Number	:	1407191745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALBA GRACIELA PUENTES AGUSTIN LMFT

Provider Business Mailing Address
First Line	:	9750 W SKYE CANYON PARK DR STE 160-290
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-6623
Country	:	US
Telephone Number	:	702-570-8967
Fax Number	:

Provider Business Practice Location Address
First Line	:	9750 W SKYE CANYON PARK DR STE 160-290
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-6623
Country	:	US
Telephone Number	:	702-570-8967
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2012
Last Update Date	:	10/04/2024

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