Provider Demographics
NPI:1194125625
Name:KEOVONGSA, KHAMPHADY (LICSW)
Entity type:Individual
Prefix:
First Name:KHAMPHADY
Middle Name:
Last Name:KEOVONGSA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 STANDISH RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-7069
Mailing Address - Country:US
Mailing Address - Phone:781-999-4975
Mailing Address - Fax:617-812-1596
Practice Address - Street 1:30 STANDISH RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-7069
Practice Address - Country:US
Practice Address - Phone:781-999-4975
Practice Address - Fax:801-263-4333
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9455497-35011041C0700X
UT9455497-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical