Provider Demographics
NPI:1679979033
Name:SOTELO, EDGAR IVAN
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:IVAN
Last Name:SOTELO
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 1:6512 N DECATUR BLVD STE 130-114
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-1046
Mailing Address - Country:US
Mailing Address - Phone:702-994-3635
Mailing Address - Fax:702-664-0648
Practice Address - Street 1:730 N EASTREN AVE STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-2885
Practice Address - Country:US
Practice Address - Phone:702-994-3635
Practice Address - Fax:702-664-0648
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health