MEDICARE: SOTHAVY NORODOM

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	106H00000X	Marriage & Family Therapist	111867	CA

General Provider Information

NPI Number	:	1528525078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOTHAVY NORODOM

Provider Business Mailing Address
First Line	:	2436 E 4TH ST # 587
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90814-1156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2436 E 4TH ST # 587
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90814-1156
Country	:	US
Telephone Number	:	213-444-3936
Fax Number	:

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

Provider Enumeration Date	:	02/20/2019
Last Update Date	:	10/09/2020

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Directions to “ SOTHAVY NORODOM ” Practice Location

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