Provider Demographics
NPI:1144656240
Name:SOMTAKOUNE, SALEUMDETH RICHARD
Entity type:Individual
Prefix:
First Name:SALEUMDETH
Middle Name:RICHARD
Last Name:SOMTAKOUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 W SHAW LN STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2777
Mailing Address - Country:US
Mailing Address - Phone:559-443-4800
Mailing Address - Fax:
Practice Address - Street 1:2560 W SHAW LN STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2777
Practice Address - Country:US
Practice Address - Phone:559-443-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2024-07-02
Deactivation Date:2020-08-17
Deactivation Code:
Reactivation Date:2020-08-28
Provider Licenses
StateLicense IDTaxonomies
CA8064104100000X
CA16845101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker