MEDICARE: MR. SANTI Y SOUMPHOLPHAKDY LCSW

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	104100000X	Social Worker	26030	CA
2	1041C0700X	Clinical Social Worker	26030	CA

General Provider Information

NPI Number	:	1174663488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SANTI Y SOUMPHOLPHAKDY LCSW

Provider Business Mailing Address
First Line	:	545 ESTUDILLO AVE
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-4611
Country	:	US
Telephone Number	:	510-352-9200
Fax Number	:	510-352-3120

Provider Business Practice Location Address
First Line	:	545 ESTUDILLO AVE
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-4611
Country	:	US
Telephone Number	:	510-352-9200
Fax Number	:	510-352-3120

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	09/24/2012

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