MEDICARE: DR RONALD PAK PSYD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861072456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR RONALD PAK PSYD, LLC

Provider Business Mailing Address
First Line	:	7341 W CHARLESTON BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-1573
Country	:	US
Telephone Number	:	702-981-0735
Fax Number	:

Provider Business Practice Location Address
First Line	:	7341 W CHARLESTON BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-1573
Country	:	US
Telephone Number	:	702-981-0735
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RONALD PAK
Credential	:	PSYD, LMFT
Telephone Number	:	702-981-0735

Provider Enumeration Date	:	04/09/2021
Last Update Date	:	04/09/2021

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