Healthcare Provider Details

I. General information

NPI: 1336347111
Provider Name (Legal Business Name): SOTHA CHHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 PACIFIC AVE
LONG BEACH CA
90806
US

IV. Provider business mailing address

2390 PACIFIC AVE
LONG BEACH CA
90806-3051
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-1863
  • Fax:
Mailing address:
  • Phone: 562-988-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105193
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: