Provider Demographics
NPI:1003110990
Name:PHOMTHAVONG, ANDREW KEODARA (MSW)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:KEODARA
Last Name:PHOMTHAVONG
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-1848
Mailing Address - Country:US
Mailing Address - Phone:619-743-9052
Mailing Address - Fax:
Practice Address - Street 1:298 WALKER STREET
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851
Practice Address - Country:US
Practice Address - Phone:619-743-9052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicare Oscar/Certification