Provider Demographics
NPI:1831513233
Name:LY, PHONG
Entity type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:LY
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 1:3639 MARTIN LUTHER KING JR WAY S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-6847
Mailing Address - Country:US
Mailing Address - Phone:206-774-2443
Mailing Address - Fax:206-695-7606
Practice Address - Street 1:3639 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-6847
Practice Address - Country:US
Practice Address - Phone:206-774-2443
Practice Address - Fax:206-695-7606
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2111587Medicaid