Provider Demographics
NPI:1477000958
Name:PHONHNABOTH, BOUNRATTANAPASONG (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:BOUNRATTANAPASONG
Middle Name:
Last Name:PHONHNABOTH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MICKIE
Other - Middle Name:
Other - Last Name:PHONHNABOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7425 W AZURE DR STE 140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-4425
Mailing Address - Country:US
Mailing Address - Phone:702-515-4009
Mailing Address - Fax:702-553-3438
Practice Address - Street 1:6345 S JONES BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3334
Practice Address - Country:US
Practice Address - Phone:702-515-4009
Practice Address - Fax:702-553-3438
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTA-2887224Z00000X
TX213493224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant