Healthcare Provider Details

I. General information

NPI: 1821156498
Provider Name (Legal Business Name): PHOUANGMALY PHIMVONGSA L.P.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALY PHIMVONGSA LPC

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 MAIN ST
WINDSOR LOCKS CT
06096-2325
US

IV. Provider business mailing address

82 MAIN ST
WINDSOR LOCKS CT
06096-2325
US

V. Phone/Fax

Practice location:
  • Phone: 860-254-5127
  • Fax: 860-310-4235
Mailing address:
  • Phone: 860-254-5127
  • Fax: 860-310-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number001470
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: