Provider Demographics
NPI:1588839203
Name:BRALLIAR PSYCHIATRIC ASSOCIATES PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRALLIAR PSYCHIATRIC ASSOCIATES PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORRETTO
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-838-3889
Mailing Address - Street 1:PO BOX 33820
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-3820
Mailing Address - Country:US
Mailing Address - Phone:702-876-9330
Mailing Address - Fax:702-876-9061
Practice Address - Street 1:2445 FIRE MESA ST
Practice Address - Street 2:SUITE 270
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9014
Practice Address - Country:US
Practice Address - Phone:702-876-9330
Practice Address - Fax:702-876-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019185Medicaid
NV1578520896OtherPERSONAL NPI
NV002019185Medicaid
V30290Medicare PIN