Healthcare Provider Details

I. General information

NPI: 1265671895
Provider Name (Legal Business Name): RONALD D FAGGINS M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HARD KNOX REHABILITATION AND MENTORING SERVICE 7473 W LAKE MEAD BLVD
LAS VEGAS NV
89128
US

IV. Provider business mailing address

8461 FARM RD STE 120
LAS VEGAS NV
89131-8306
US

V. Phone/Fax

Practice location:
  • Phone: 702-562-1288
  • Fax:
Mailing address:
  • Phone: 215-651-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCP5312
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: