Basic Information
| Provider Information | |||||||||
| NPI: | 1730591637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACHECO | ||||||||
| FirstName: | GRACIELA | ||||||||
| MiddleName: | YASMIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OHIKERE (PACHECO) | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | LILLIANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3275 SOUTH JONES BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028000684 | ||||||||
| FaxNumber: | 5105354167 | ||||||||
| Practice Location | |||||||||
| Address1: | 3275 SOUTH JONES BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028000684 | ||||||||
| FaxNumber: | 5105354167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 4352-R | NV | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 90751 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.