Provider Demographics
NPI:1942534110
Name:VANG, SOUA (MA)
Entity type:Individual
Prefix:MS
First Name:SOUA
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 MARCH DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3219
Mailing Address - Country:US
Mailing Address - Phone:530-521-4643
Mailing Address - Fax:209-758-0825
Practice Address - Street 1:17000 S HARLAN RD
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8738
Practice Address - Country:US
Practice Address - Phone:209-647-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103K00000X
CA122145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst