Provider Demographics
NPI:1316187362
Name:SOUS, SOKCHEAR S
Entity Type:Individual
Prefix:
First Name:SOKCHEAR
Middle Name:S
Last Name:SOUS
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 1:800 SCENIC DR.
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-558-4600
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERE
Practice Address - State:CA
Practice Address - Zip Code:95307-2330
Practice Address - Country:US
Practice Address - Phone:209-558-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2024-02-27
Deactivation Date:2022-09-02
Deactivation Code:
Reactivation Date:2023-02-23
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA95268104163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator