Provider Demographics
NPI:1508129222
Name:SHUFFER, SIRIVANH KONGBOUAKHAY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SIRIVANH
Middle Name:KONGBOUAKHAY
Last Name:SHUFFER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 VAN BUREN DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91755-4150
Mailing Address - Country:US
Mailing Address - Phone:559-970-4155
Mailing Address - Fax:
Practice Address - Street 1:429 VAN BUREN DR
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91755-4150
Practice Address - Country:US
Practice Address - Phone:559-970-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25332101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health