Provider Demographics
NPI:1124866017
Name:POGO FUENTES, GABRIELA FERNANDA
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:FERNANDA
Last Name:POGO FUENTES
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 1:3450 N HUALAPAI WAY UNIT 1143
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8069
Mailing Address - Country:US
Mailing Address - Phone:775-453-5866
Mailing Address - Fax:
Practice Address - Street 1:3930 HOWARD HUGHES PKWY STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-0946
Practice Address - Country:US
Practice Address - Phone:702-560-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-24-354230106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician