Basic Information
| Provider Information | |||||||||
| NPI: | 1235384066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRAVONGVIENGKHAM | ||||||||
| FirstName: | NIDIA | ||||||||
| MiddleName: | DELSY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOLINA | ||||||||
| OtherFirstName: | NIDIA | ||||||||
| OtherMiddleName: | DELSY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13415 CANTERBURY DOWNS WAY | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925558402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518930089 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13800 HEACOCK ST STE C236 | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925533364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516530819 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2008 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 54676 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.