Provider Demographics
NPI:1346387750
Name:PHATH, BOUNTHAY
Entity Type:Individual
Prefix:
First Name:BOUNTHAY
Middle Name:
Last Name:PHATH
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 1:24 CORA ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-3032
Mailing Address - Country:US
Mailing Address - Phone:617-912-7733
Mailing Address - Fax:781-286-5636
Practice Address - Street 1:265 BEACH ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3131
Practice Address - Country:US
Practice Address - Phone:617-912-7733
Practice Address - Fax:781-286-5636
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301659Medicaid