Healthcare Provider Details

I. General information

NPI: 1033245857
Provider Name (Legal Business Name): KEVIN PANYANOUVONG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCENIC DR
MODESTO CA
95350-6131
US

IV. Provider business mailing address

800 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-6225
  • Fax: 209-558-4326
Mailing address:
  • Phone: 209-525-6225
  • Fax: 209-558-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: