Provider Demographics
NPI:1164986246
Name:THAMMAVONG, SOUKTHANOME (LICSW)
Entity Type:Individual
Prefix:
First Name:SOUKTHANOME
Middle Name:
Last Name:THAMMAVONG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:NOME
Other - Middle Name:
Other - Last Name:THAMMAVONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:2001 BLOOMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-249-0941
Mailing Address - Fax:
Practice Address - Street 1:4111 CENTRAL AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-2960
Practice Address - Country:US
Practice Address - Phone:763-283-7194
Practice Address - Fax:612-437-4535
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical