Provider Demographics
NPI:1518735117
Name:CERVANTES, JOHNNY JR
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:CERVANTES
Suffix:JR
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 1:5540 W HARMON AVE APT 1038
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5125
Mailing Address - Country:US
Mailing Address - Phone:702-504-4334
Mailing Address - Fax:
Practice Address - Street 1:3130 S DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-4455
Practice Address - Country:US
Practice Address - Phone:702-319-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst