Provider Demographics
NPI:1821156498
Name:PHIMVONGSA, PHOUANGMALY (LPC)
Entity Type:Individual
Prefix:
First Name:PHOUANGMALY
Middle Name:
Last Name:PHIMVONGSA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MALY
Other - Middle Name:
Other - Last Name:PHIMVONGSA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:82 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-2325
Mailing Address - Country:US
Mailing Address - Phone:860-254-5127
Mailing Address - Fax:860-310-4235
Practice Address - Street 1:82 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR LOCKS
Practice Address - State:CT
Practice Address - Zip Code:06096-2325
Practice Address - Country:US
Practice Address - Phone:860-254-5127
Practice Address - Fax:860-310-4235
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001470101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257053Medicaid