Provider Demographics
NPI:1023720810
Name:PHONGSA, MONICA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:PHONGSA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 LIBERTY HWY
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:457 LIBERTY HWY
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2721
Practice Address - Country:US
Practice Address - Phone:860-942-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4675235Z00000X
WA61339861235Z00000X
CA32745235Z00000X
MA77694235Z00000X
CT6165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist