Healthcare Provider Details

I. General information

NPI: 1578281119
Provider Name (Legal Business Name): NANCY KHANTHAVONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1563 MISSION ST
SAN FRANCISCO CA
94103-2543
US

IV. Provider business mailing address

3215 BALBOA ST
SAN FRANCISCO CA
94121-2731
US

V. Phone/Fax

Practice location:
  • Phone: 415-762-3700
  • Fax:
Mailing address:
  • Phone: 415-299-5822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1446871021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: