Provider Demographics
NPI:1013182559
Name:AMEZAGA, ALFREDO M JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:M
Last Name:AMEZAGA
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18124 WEDGE PKWY
Mailing Address - Street 2:STE. 538
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-8134
Mailing Address - Country:US
Mailing Address - Phone:800-401-5593
Mailing Address - Fax:800-401-5593
Practice Address - Street 1:18124 WEDGE PKWY
Practice Address - Street 2:STE. 538
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8134
Practice Address - Country:US
Practice Address - Phone:800-401-5593
Practice Address - Fax:800-401-5593
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14696101YA0400X, 103TB0200X, 103TC0700X, 103TF0200X, 103TR0400X
NVPY0327103TA0400X, 103TB0200X, 103TC0700X, 103TF0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation