Provider Demographics
NPI:1508747791
Name:PHANTHAVONG, LINDA NANG (LICSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:NANG
Last Name:PHANTHAVONG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 BOONE AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3636
Mailing Address - Country:US
Mailing Address - Phone:612-542-8089
Mailing Address - Fax:
Practice Address - Street 1:6400 74TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-1420
Practice Address - Country:US
Practice Address - Phone:612-816-9369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN319621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty