Provider Demographics
NPI:1679276380
Name:PHANNGOEN, SUPAVINEE
Entity Type:Individual
Prefix:
First Name:SUPAVINEE
Middle Name:
Last Name:PHANNGOEN
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 1:12804 BLUHILL RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-4026
Mailing Address - Country:US
Mailing Address - Phone:301-267-0368
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE # LL
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health