Healthcare Provider Details

I. General information

NPI: 1942516976
Provider Name (Legal Business Name): BOUNSANG KHAMKEO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SW ALDER ST 520 SUITE
PORTLAND OR
97205-3626
US

IV. Provider business mailing address

2406 E 27TH ST
VANCOUVER WA
98661-3917
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4745
  • Fax:
Mailing address:
  • Phone: 360-944-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number03-P-06
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: