MEDICARE: NICOLAS PONZO, LCSW, LTD

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	1041C0700X	Clinical Social Worker	01258C	NV

General Provider Information

NPI Number	:	1821388109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLAS PONZO, LCSW, LTD

Provider Business Mailing Address
First Line	:	10161 PARK RUN DR
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-8871
Country	:	US
Telephone Number	:	702-248-1169
Fax Number	:

Provider Business Practice Location Address
First Line	:	10161 PARK RUN DR
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-8871
Country	:	US
Telephone Number	:	702-248-1169
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. NICOLAS PONZO
Credential	:	LCSW, M.ED
Telephone Number	:	702-248-1169

Provider Enumeration Date	:	04/08/2011
Last Update Date	:	04/08/2011

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