Healthcare Provider Details

I. General information

NPI: 1710327044
Provider Name (Legal Business Name): PANGCHEE MYER MOUAVANGSOU AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 W CLINTON AVE UNIT 311
FRESNO CA
93705-4218
US

IV. Provider business mailing address

2550 W CLINTON AVE UNIT 311
FRESNO CA
93705-4218
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-7521
  • Fax:
Mailing address:
  • Phone: 559-264-7521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: