Provider Demographics
NPI:1932793825
Name:MENZOR, GEORGE ERNIE (PT)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:ERNIE
Last Name:MENZOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5373 S MARYLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-2622
Mailing Address - Country:US
Mailing Address - Phone:951-922-5073
Mailing Address - Fax:
Practice Address - Street 1:3950 W HARMON AVE UNIT 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5512
Practice Address - Country:US
Practice Address - Phone:954-922-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2354443103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty