Provider Demographics
NPI:1912205089
Name:WESLEY, JOHNNIE
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:WESLEY
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 1:4050 SPARROW ROCK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3285
Mailing Address - Country:US
Mailing Address - Phone:559-283-6625
Mailing Address - Fax:
Practice Address - Street 1:4050 SPARROW ROCK ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-3285
Practice Address - Country:US
Practice Address - Phone:559-283-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor