Provider Demographics
NPI:1033245857
Name:PANYANOUVONG, KEVIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:PANYANOUVONG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-525-6225
Mailing Address - Fax:209-558-4326
Practice Address - Street 1:800 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-6225
Practice Address - Fax:209-558-4326
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA259991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional