Provider Demographics
NPI:1962010363
Name:CHHUM, SOKHA
Entity Type:Individual
Prefix:
First Name:SOKHA
Middle Name:
Last Name:CHHUM
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 1:40 ROSE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6937
Mailing Address - Country:US
Mailing Address - Phone:781-632-4969
Mailing Address - Fax:
Practice Address - Street 1:40 ROSE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-6937
Practice Address - Country:US
Practice Address - Phone:781-632-4969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician