Healthcare Provider Details

I. General information

NPI: 1114782679
Provider Name (Legal Business Name): SENGTHONG SITHOUNNOLAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 FAIRFAX AVE STE B
SAN FRANCISCO CA
94124-3040
US

IV. Provider business mailing address

3801 3RD ST STE 400
SAN FRANCISCO CA
94124-1409
US

V. Phone/Fax

Practice location:
  • Phone: 628-217-5220
  • Fax: 415-641-3815
Mailing address:
  • Phone: 628-217-7000
  • Fax: 628-217-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: