Provider Demographics
NPI:1033868807
Name:MONG, KAMRYAN (LAC)
Entity type:Individual
Prefix:
First Name:KAMRYAN
Middle Name:
Last Name:MONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1841
Mailing Address - Country:US
Mailing Address - Phone:888-710-8220
Mailing Address - Fax:866-573-0761
Practice Address - Street 1:208 MCAULEY CT STE B
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6344
Practice Address - Country:US
Practice Address - Phone:888-710-8220
Practice Address - Fax:866-573-0761
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2308010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR280214795Medicaid