Provider Demographics
NPI:1982987640
Name:KONG, VANNAK (BA)
Entity Type:Individual
Prefix:MR
First Name:VANNAK
Middle Name:
Last Name:KONG
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 BLODGETT ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-4631
Mailing Address - Country:US
Mailing Address - Phone:978-761-6815
Mailing Address - Fax:978-275-6480
Practice Address - Street 1:35 JOHN ST FL 1
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1101
Practice Address - Country:US
Practice Address - Phone:978-275-3879
Practice Address - Fax:978-275-6480
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health