Healthcare Provider Details

I. General information

NPI: 1417456005
Provider Name (Legal Business Name): MARILYN STRADA PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8565 S EASTERN AVE STE 152
LAS VEGAS NV
89123-2906
US

IV. Provider business mailing address

8565 S EASTERN AVE STE 152
LAS VEGAS NV
89123-2906
US

V. Phone/Fax

Practice location:
  • Phone: 562-274-8203
  • Fax: 562-478-4575
Mailing address:
  • Phone: 702-635-6555
  • Fax: 562-478-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPYO811
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPYO811
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPYO811
License Number StateNV

VIII. Authorized Official

Name: DR. MARILYN STRADA
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 702-635-6555