MEDICARE: SOUKTHANOME THAMMAVONG LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1164986246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOUKTHANOME THAMMAVONG LICSW

Provider Business Mailing Address
First Line	:	2001 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-3074
Country	:	US
Telephone Number	:	612-249-0941
Fax Number	:

Provider Business Practice Location Address
First Line	:	4111 CENTRAL AVE NE STE 201
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-2960
Country	:	US
Telephone Number	:	763-283-7194
Fax Number	:	612-437-4535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2019
Last Update Date	:	04/25/2019

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