Provider Demographics
NPI:1235384066
Name:PRAVONGVIENGKHAM, NIDIA DELSY (MS)
Entity Type:Individual
Prefix:MRS
First Name:NIDIA
Middle Name:DELSY
Last Name:PRAVONGVIENGKHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:NIDIA
Other - Middle Name:DELSY
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:13415 CANTERBURY DOWNS WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-8402
Mailing Address - Country:US
Mailing Address - Phone:951-893-0089
Mailing Address - Fax:
Practice Address - Street 1:13800 HEACOCK ST STE C236
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3364
Practice Address - Country:US
Practice Address - Phone:951-653-0819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 54676106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist