MEDICARE: PATARASIRI VIRUTAMAVONGSA

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1528472172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATARASIRI VIRUTAMAVONGSA

Provider Business Mailing Address
First Line	:	1523 CORINTH AVE APT 5
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-3292
Country	:	US
Telephone Number	:	310-977-8010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 CORINTH AVE APT 5
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-3292
Country	:	US
Telephone Number	:	310-977-8010
Fax Number	:

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

Provider Enumeration Date	:	06/11/2014
Last Update Date	:	06/11/2014

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