Provider Demographics
NPI:1003127499
Name:REZANOV, MARYSOL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARYSOL
Middle Name:
Last Name:REZANOV
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARYSOL
Other - Middle Name:
Other - Last Name:AMEZCUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4170 S DECATUR BLVD STE C1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5863
Mailing Address - Country:US
Mailing Address - Phone:702-659-8827
Mailing Address - Fax:702-852-0984
Practice Address - Street 1:4170 S DECATUR BLVD STE C1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5863
Practice Address - Country:US
Practice Address - Phone:702-659-8827
Practice Address - Fax:702-852-0984
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6215-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1598015240OtherGROUP NPI