Provider Demographics
NPI:1942534110
Name:VANG, MARY SOUA (MA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SOUA
Last Name:VANG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SOUA
Other - Middle Name:MARY
Other - Last Name:VANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:388 MARCH DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3219
Mailing Address - Country:US
Mailing Address - Phone:530-521-4643
Mailing Address - Fax:209-758-0825
Practice Address - Street 1:2020 STANDIFORD AVE STE F3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6531
Practice Address - Country:US
Practice Address - Phone:209-702-0139
Practice Address - Fax:209-758-0825
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103K00000X
CAAMFT109581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst