Provider Demographics
NPI:1407126469
Name:PANYANOUVONG, TOMMY PHOUKHAOTHONG
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:PHOUKHAOTHONG
Last Name:PANYANOUVONG
Suffix:
Gender:M
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:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-558-4464
Mailing Address - Fax:
Practice Address - Street 1:1300 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-4821
Practice Address - Country:US
Practice Address - Phone:209-541-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-IUXREV171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health