Provider Demographics
NPI:1942516976
Name:KHAMKEO, BOUNSANG
Entity type:Individual
Prefix:
First Name:BOUNSANG
Middle Name:
Last Name:KHAMKEO
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 1:2406 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3917
Mailing Address - Country:US
Mailing Address - Phone:360-944-7380
Mailing Address - Fax:
Practice Address - Street 1:621 SW ALDER ST
Practice Address - Street 2:520 SUITE
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3626
Practice Address - Country:US
Practice Address - Phone:503-494-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR03-P-06101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)