=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982987640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANNAK KONG BA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2011
-----------------------------------------------------
Last Update Date | 09/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 JOHN ST FL 1
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01852-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-275-3879
-----------------------------------------------------
Fax | 978-275-6480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 BLODGETT ST
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01851-4631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-761-6815
-----------------------------------------------------
Fax | 978-275-6480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------