Healthcare Provider Details

I. General information

NPI: 1023720810
Provider Name (Legal Business Name): MONICA PHONGSA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2022
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MELINDA TER
DANIELSON CT
06239-1517
US

IV. Provider business mailing address

30 MELINDA TER
DANIELSON CT
06239-1517
US

V. Phone/Fax

Practice location:
  • Phone: 860-942-9619
  • Fax:
Mailing address:
  • Phone: 860-942-9619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number32745
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4675
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number61339861
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146028904
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number77694
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6165
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number208919
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: