Provider Demographics
NPI:1184246597
Name:DEFIESTA, PAUL LAWRENCE A (MSW, LCSWA, LMSW)
Entity type:Individual
Prefix:MR
First Name:PAUL LAWRENCE
Middle Name:A
Last Name:DEFIESTA
Suffix:
Gender:M
Credentials:MSW, LCSWA, LMSW
Other - Prefix:MR
Other - First Name:LAWRENCE
Other - Middle Name:A
Other - Last Name:DEFIESTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LCSWA
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-2273
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0144901041C0700X
NV10499-M1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical