Provider Demographics
NPI:1861072456
Name:DR RONALD PAK PSYD, LLC
Entity type:Organization
Organization Name:DR RONALD PAK PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMFT
Authorized Official - Phone:702-981-0735
Mailing Address - Street 1:7341 W CHARLESTON BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1573
Mailing Address - Country:US
Mailing Address - Phone:702-981-0735
Mailing Address - Fax:
Practice Address - Street 1:7341 W CHARLESTON BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1573
Practice Address - Country:US
Practice Address - Phone:702-981-0735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1404256613Medicaid