Healthcare Provider Details

I. General information

NPI: 1922946706
Provider Name (Legal Business Name): PRAGUE ROBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 RAMONA BLVD STE J
IRWINDALE CA
91706-3752
US

IV. Provider business mailing address

4015 3RD AVE
LOS ANGELES CA
90008-2707
US

V. Phone/Fax

Practice location:
  • Phone: 646-525-6003
  • Fax:
Mailing address:
  • Phone: 646-525-6003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number162007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: