Provider Demographics
NPI:1124421953
Name:MILAZZO, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:MILAZZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TREVOR
Other - Middle Name:
Other - Last Name:MILAZZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSR
Mailing Address - Street 1:6869 TAMARUS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-0391
Mailing Address - Country:US
Mailing Address - Phone:201-925-0779
Mailing Address - Fax:702-257-9411
Practice Address - Street 1:121 E SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3518
Practice Address - Country:US
Practice Address - Phone:201-925-0779
Practice Address - Fax:702-257-9411
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NV8975-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1099Medicaid