Provider Demographics
NPI:1265973861
Name:PAK, BRIAN (BA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PAK
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1028
Mailing Address - Country:US
Mailing Address - Phone:736-736-3777
Mailing Address - Fax:
Practice Address - Street 1:12334 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89505
Practice Address - Country:US
Practice Address - Phone:636-737-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist