Provider Demographics
NPI:1699397596
Name:VANG, XAINYAVONG
Entity Type:Individual
Prefix:
First Name:XAINYAVONG
Middle Name:
Last Name:VANG
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 1:28326 TERESA SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:TOLLHOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:93667-9707
Mailing Address - Country:US
Mailing Address - Phone:559-288-2112
Mailing Address - Fax:
Practice Address - Street 1:412 F ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3409
Practice Address - Country:US
Practice Address - Phone:559-498-6689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7454101YM0800X
CAAPCC7454101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health