Provider Demographics
NPI:1699250969
Name:SOUKHANOUVONG, NISHTHAYA (PSYD)
Entity type:Individual
Prefix:DR
First Name:NISHTHAYA
Middle Name:
Last Name:SOUKHANOUVONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:SOUKHANOUVONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3743 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1164
Mailing Address - Country:US
Mailing Address - Phone:704-826-2709
Mailing Address - Fax:571-257-0906
Practice Address - Street 1:3743 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1164
Practice Address - Country:US
Practice Address - Phone:704-826-2709
Practice Address - Fax:571-257-0906
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical