Provider Demographics
NPI:1497234454
Name:KHOUNSOMBATH, ERICA ALLISON
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:ALLISON
Last Name:KHOUNSOMBATH
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 1:23 BOTANY BAY RD APT 7
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-3484
Mailing Address - Country:US
Mailing Address - Phone:508-843-2618
Mailing Address - Fax:
Practice Address - Street 1:8 FANEUIL HALL MARKETPLACE FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-6114
Practice Address - Country:US
Practice Address - Phone:888-329-4535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician