Provider Demographics
NPI:1912475476
Name:THATSANAVONGSA, RICKY
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:
Last Name:THATSANAVONGSA
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 1:2100 24TH AVE S STE 260
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-4644
Mailing Address - Country:US
Mailing Address - Phone:206-446-8813
Mailing Address - Fax:
Practice Address - Street 1:2100 24TH AVE S STE 260
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-4644
Practice Address - Country:US
Practice Address - Phone:206-446-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1026117Medicaid