Provider Demographics
NPI:1376883371
Name:GANDARILLA, MARIELENA
Entity Type:Individual
Prefix:
First Name:MARIELENA
Middle Name:
Last Name:GANDARILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8617 HIDDEN PINES AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-1367
Mailing Address - Country:US
Mailing Address - Phone:702-353-7193
Mailing Address - Fax:
Practice Address - Street 1:3680 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3180
Practice Address - Country:US
Practice Address - Phone:702-869-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst