Provider Demographics
NPI:1578991485
Name:PASSALACQUA, PEDRO GINO
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:GINO
Last Name:PASSALACQUA
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 1:5575 SIMMONS ST
Mailing Address - Street 2:1-363
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-9009
Mailing Address - Country:US
Mailing Address - Phone:702-202-2567
Mailing Address - Fax:702-202-6919
Practice Address - Street 1:3105 COLEMAN ST
Practice Address - Street 2:B
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3807
Practice Address - Country:US
Practice Address - Phone:702-202-2567
Practice Address - Fax:702-202-6919
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor