1912178310 NPI number — DR. PHOUKHAM KELLY BOUNKEUA PHD

Table of content: DR. PHOUKHAM KELLY BOUNKEUA PHD (NPI 1912178310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912178310 NPI number — DR. PHOUKHAM KELLY BOUNKEUA PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUNKEUA
Provider First Name:
PHOUKHAM
Provider Middle Name:
KELLY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOUNKEUA
Provider Other First Name:
P
Provider Other Middle Name:
KELLY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA LMHC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1912178310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16040 CHRISTENSEN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUKWILA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-431-5336
Provider Business Mailing Address Fax Number:
206-431-5430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16040 CHRISTENSEN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUKWILA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-391-0887
Provider Business Practice Location Address Fax Number:
425-391-7014
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH00003666 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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