Provider Demographics
NPI:1598038127
Name:PEN, SOVANN DARA (LPC)
Entity Type:Individual
Prefix:MR
First Name:SOVANN
Middle Name:DARA
Last Name:PEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SE 14TH AVE
Mailing Address - Street 2:#104
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1404
Mailing Address - Country:US
Mailing Address - Phone:571-207-4718
Mailing Address - Fax:
Practice Address - Street 1:12 SE 14TH AVE
Practice Address - Street 2:#104
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1404
Practice Address - Country:US
Practice Address - Phone:571-207-4718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional