Provider Demographics
NPI:1912690512
Name:SOPAPONG, PAKAWADEE (PT)
Entity type:Individual
Prefix:
First Name:PAKAWADEE
Middle Name:
Last Name:SOPAPONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 5TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1290
Mailing Address - Country:US
Mailing Address - Phone:304-525-4445
Mailing Address - Fax:304-529-7449
Practice Address - Street 1:286 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-1236
Practice Address - Country:US
Practice Address - Phone:513-539-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004651225100000X
OH021482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist