Provider Demographics
NPI:1003335654
Name:SLAYDEN, PORNPHUN
Entity Type:Individual
Prefix:
First Name:PORNPHUN
Middle Name:
Last Name:SLAYDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15305 RAYEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5117
Mailing Address - Country:US
Mailing Address - Phone:818-892-3423
Mailing Address - Fax:818-893-4509
Practice Address - Street 1:20 WINOOSKI FALLS WAY STE 400
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-2239
Practice Address - Country:US
Practice Address - Phone:802-857-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123258106H00000X
UT12789279-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist