Provider Demographics
NPI:1043988785
Name:PHONGSAVATH, DARLEEN
Entity Type:Individual
Prefix:
First Name:DARLEEN
Middle Name:
Last Name:PHONGSAVATH
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 1:7339 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2954
Mailing Address - Country:US
Mailing Address - Phone:559-207-4929
Mailing Address - Fax:
Practice Address - Street 1:5175 N FRESNO ST APT 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6859
Practice Address - Country:US
Practice Address - Phone:559-515-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician