Provider Demographics
NPI:1336481696
Name:JOHNSON, GAVIN LANELL
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:LANELL
Last Name:JOHNSON
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 1:7720 COWBOY TRAIL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131
Mailing Address - Country:US
Mailing Address - Phone:702-510-3790
Mailing Address - Fax:
Practice Address - Street 1:7720 COWBOY TRL
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-2131
Practice Address - Country:US
Practice Address - Phone:702-510-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1164669479Medicaid