Provider Demographics
NPI:1942509930
Name:WOTELL, JONATHAN R (CPC I)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:R
Last Name:WOTELL
Suffix:
Gender:M
Credentials:CPC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 S. PECOS ROAD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120
Mailing Address - Country:US
Mailing Address - Phone:702-685-0877
Mailing Address - Fax:702-749-5922
Practice Address - Street 1:5631 S. PECOS ROAD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120
Practice Address - Country:US
Practice Address - Phone:702-685-0877
Practice Address - Fax:702-749-5922
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI1599101YP2500X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner