Provider Demographics
NPI:1619218245
Name:PAGALAN, BERENISE
Entity Type:Individual
Prefix:
First Name:BERENISE
Middle Name:
Last Name:PAGALAN
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 1:5710 OLD COLONY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4660 S EASTERN AVE
Practice Address - Street 2:STE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6137
Practice Address - Country:US
Practice Address - Phone:702-457-7542
Practice Address - Fax:702-450-4239
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health