Provider Demographics
NPI:1477098333
Name:SIACKASORN, MOUKDAVANH
Entity Type:Individual
Prefix:
First Name:MOUKDAVANH
Middle Name:
Last Name:SIACKASORN
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 1:2311 LOVERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-5117
Mailing Address - Country:US
Mailing Address - Phone:925-431-2654
Mailing Address - Fax:925-431-2644
Practice Address - Street 1:2311 LOVERIDGE RD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5117
Practice Address - Country:US
Practice Address - Phone:925-431-2654
Practice Address - Fax:925-431-2644
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA942271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical