Healthcare Provider Details

I. General information

NPI: 1053830166
Provider Name (Legal Business Name): EVAN PAIK PHD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-4502
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0810008269
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: