Provider Demographics
NPI:1508263559
Name:VONGPHRACHANH, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:VONGPHRACHANH
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 1:2402 ARLINE ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2114
Mailing Address - Country:US
Mailing Address - Phone:510-666-7733
Mailing Address - Fax:
Practice Address - Street 1:55 AUBURN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-1847
Practice Address - Country:US
Practice Address - Phone:626-355-1729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9529235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist