Provider Demographics
NPI:1790064012
Name:WONGTHAVATCHAI, DANIEL D (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:WONGTHAVATCHAI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E FOOTHILL BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2361
Mailing Address - Country:US
Mailing Address - Phone:626-701-4249
Mailing Address - Fax:626-737-6034
Practice Address - Street 1:41 E FOOTHILL BLVD
Practice Address - Street 2:STE 102
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2361
Practice Address - Country:US
Practice Address - Phone:626-701-4249
Practice Address - Fax:626-737-6034
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33235101YM0800X
CA884221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health