Provider Demographics
NPI:1962884064
Name:WONNACOTT, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WONNACOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3852 PALOS VERDES ST
Mailing Address - Street 2:SUITE 40
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6909
Mailing Address - Country:US
Mailing Address - Phone:702-485-1300
Mailing Address - Fax:
Practice Address - Street 1:3852 PALOS VERDES ST
Practice Address - Street 2:SUITE 40
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6909
Practice Address - Country:US
Practice Address - Phone:702-485-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV251B00000XMedicaid