Provider Demographics
NPI:1225154305
Name:ETCOFF, LEWIS M (PHD)
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:M
Last Name:ETCOFF
Suffix:
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 1:8475 S EASTERN AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2862
Mailing Address - Country:US
Mailing Address - Phone:702-876-1977
Mailing Address - Fax:702-876-0238
Practice Address - Street 1:8475 S EASTERN AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2862
Practice Address - Country:US
Practice Address - Phone:702-876-1977
Practice Address - Fax:702-876-0238
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical