MEDICARE: KAMONPORN MUNBOON CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP32903	CA

General Provider Information

NPI Number	:	1902503790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAMONPORN MUNBOON CCC-SLP

Provider Business Mailing Address
First Line	:	6619 LELAND WAY APT 303
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7881
Country	:	US
Telephone Number	:	424-653-4251
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 W PICO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3643
Country	:	US
Telephone Number	:	323-734-2171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2023
Last Update Date	:	02/13/2023

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