Provider Demographics
NPI:1992840789
Name:STRADA, MARILYN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:J
Last Name:STRADA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8565 S EASTERN AVE STE 152
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2906
Mailing Address - Country:US
Mailing Address - Phone:702-635-6555
Mailing Address - Fax:562-478-4575
Practice Address - Street 1:8565 S EASTERN AVE STE 152
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2906
Practice Address - Country:US
Practice Address - Phone:562-274-8203
Practice Address - Fax:562-478-4575
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPYO811103T00000X, 103TB0200X, 103TC0700X, 103TH0004X, 103G00000X, 103TH0004X
CAPSY22500103TA0400X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
82-3676424OtherTIN
CA95-4871965OtherITIN