Provider Demographics
NPI:1194163980
Name:EZETA, CARLOS JAVIER (MS, MED)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:JAVIER
Last Name:EZETA
Suffix:
Gender:M
Credentials:MS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312 OBANNON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3043
Mailing Address - Country:US
Mailing Address - Phone:702-423-3838
Mailing Address - Fax:
Practice Address - Street 1:6312 OBANNON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3043
Practice Address - Country:US
Practice Address - Phone:702-423-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor