Provider Demographics
NPI:1891389821
Name:DUONG, KHANH
Entity Type:Individual
Prefix:
First Name:KHANH
Middle Name:
Last Name:DUONG
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 1:142 N RUSH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-3225
Mailing Address - Country:US
Mailing Address - Phone:773-312-1311
Mailing Address - Fax:
Practice Address - Street 1:510 E MOELLER ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2612
Practice Address - Country:US
Practice Address - Phone:928-420-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10751106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist