Provider Demographics
NPI:1962593806
Name:DISAVINO, ANDREW JOSEPH (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:DISAVINO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 VEGAS DR
Mailing Address - Street 2:2089
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-7707
Mailing Address - Country:US
Mailing Address - Phone:215-892-8956
Mailing Address - Fax:
Practice Address - Street 1:916 W OWENS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2516
Practice Address - Country:US
Practice Address - Phone:702-636-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-006371-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical