Provider Demographics
NPI:1982289922
Name:THAMMAVONGSA, NARRIMONE VIVID (MAT, EDS, NCSP)
Entity Type:Individual
Prefix:
First Name:NARRIMONE
Middle Name:VIVID
Last Name:THAMMAVONGSA
Suffix:
Gender:F
Credentials:MAT, EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 RUNDLE ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-2912
Mailing Address - Country:US
Mailing Address - Phone:215-879-1291
Mailing Address - Fax:
Practice Address - Street 1:1307 RUNDLE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-2912
Practice Address - Country:US
Practice Address - Phone:215-879-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool