Basic Information
| Provider Information | |||||||||
| NPI: | 1144656240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOMTAKOUNE | ||||||||
| FirstName: | SALEUMDETH | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2440 TULARE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937212281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594434800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2560 W SHAW LN STE 104 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937112777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594434800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2013 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/17/2020 | ||||||||
| NPIReactivationDate: | 08/28/2020 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 8064 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.