Provider Demographics
NPI:1942705363
Name:KHAMVONGSA, ERICA LAUREN
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:LAUREN
Last Name:KHAMVONGSA
Suffix:
Gender:F
Credentials:
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 53075
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-4075
Mailing Address - Country:US
Mailing Address - Phone:626-217-3919
Mailing Address - Fax:
Practice Address - Street 1:4033 MT VERNON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4805
Practice Address - Country:US
Practice Address - Phone:951-683-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 101Y00000X
CA132873106H00000X
CA115654106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor