Provider Demographics
NPI:1760940894
Name:KNOBLAUCH, REAGAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:ELIZABETH
Last Name:KNOBLAUCH
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 1:6333 CROMWELL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2566
Mailing Address - Country:US
Mailing Address - Phone:702-561-2183
Mailing Address - Fax:
Practice Address - Street 1:1830 E SAHARA AVE STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3739
Practice Address - Country:US
Practice Address - Phone:702-383-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-10531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical