Provider Demographics
NPI:1952873887
Name:PHOUMIPHAT, XSANA
Entity Type:Individual
Prefix:
First Name:XSANA
Middle Name:
Last Name:PHOUMIPHAT
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 1:3709 W OAKEY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-3832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3709 W OAKEY BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-3832
Practice Address - Country:US
Practice Address - Phone:702-582-3979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2022-02-24
Deactivation Date:2020-11-05
Deactivation Code:
Reactivation Date:2021-01-26
Provider Licenses
StateLicense IDTaxonomies
NVCI5057101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional