Provider Demographics
NPI:1700361565
Name:PAO, SOKSAN
Entity Type:Individual
Prefix:
First Name:SOKSAN
Middle Name:
Last Name:PAO
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 1:744 ROOSEVELT TRL STE 207
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5281
Mailing Address - Country:US
Mailing Address - Phone:207-749-4991
Mailing Address - Fax:
Practice Address - Street 1:744 ROOSEVELT TRL STE 207
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5281
Practice Address - Country:US
Practice Address - Phone:207-749-4991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC17466101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health