Provider Demographics
NPI:1154151447
Name:PHOUNSAVATH, POUKPHANH SERENA
Entity type:Individual
Prefix:
First Name:POUKPHANH
Middle Name:SERENA
Last Name:PHOUNSAVATH
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 1:343 W BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1370
Mailing Address - Country:US
Mailing Address - Phone:440-260-6835
Mailing Address - Fax:
Practice Address - Street 1:3500 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2641
Practice Address - Country:US
Practice Address - Phone:440-234-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator