Provider Demographics
NPI:1912630450
Name:THEPHAVONGSA, NATHAN SHAWN PERALTA
Entity Type:Individual
Prefix:
First Name:NATHAN SHAWN
Middle Name:PERALTA
Last Name:THEPHAVONGSA
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 1:3341 JAMI CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9149
Mailing Address - Country:US
Mailing Address - Phone:408-438-7827
Mailing Address - Fax:
Practice Address - Street 1:2829 WATT AVE STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-6245
Practice Address - Country:US
Practice Address - Phone:916-418-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA134896106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist