Provider Demographics
NPI:1891183422
Name:KONGSWANGWONGSA, LYDA
Entity Type:Individual
Prefix:
First Name:LYDA
Middle Name:
Last Name:KONGSWANGWONGSA
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 1:547 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2209
Mailing Address - Country:US
Mailing Address - Phone:909-636-8125
Mailing Address - Fax:
Practice Address - Street 1:547 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2209
Practice Address - Country:US
Practice Address - Phone:909-636-8125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist