Provider Demographics
NPI:1174663488
Name:SOUMPHOLPHAKDY, SANTI Y (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SANTI
Middle Name:Y
Last Name:SOUMPHOLPHAKDY
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 1:545 ESTUDILLO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4611
Mailing Address - Country:US
Mailing Address - Phone:510-352-9200
Mailing Address - Fax:510-352-3120
Practice Address - Street 1:545 ESTUDILLO AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4611
Practice Address - Country:US
Practice Address - Phone:510-352-9200
Practice Address - Fax:510-352-3120
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26030104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical