Provider Demographics
NPI:1114379450
Name:MANIKHAM, SOUMONTHA
Entity Type:Individual
Prefix:
First Name:SOUMONTHA
Middle Name:
Last Name:MANIKHAM
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 1:5985 RICE CREEK PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5038
Mailing Address - Country:US
Mailing Address - Phone:651-348-7240
Mailing Address - Fax:
Practice Address - Street 1:5985 RICE CREEK PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5038
Practice Address - Country:US
Practice Address - Phone:651-348-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional