Provider Demographics
NPI:1316219777
Name:ZUPAN, BRETT WAYNE
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:WAYNE
Last Name:ZUPAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 ALAMO HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3818
Mailing Address - Country:US
Mailing Address - Phone:702-354-9684
Mailing Address - Fax:
Practice Address - Street 1:2820 W CHARLESTON BLVD
Practice Address - Street 2:STE. C28
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1942
Practice Address - Country:US
Practice Address - Phone:702-675-3850
Practice Address - Fax:702-901-7596
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0691101YM0800X
225400000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner