Provider Demographics
NPI:1609027853
Name:KHEM, PHANNO
Entity type:Individual
Prefix:MR
First Name:PHANNO
Middle Name:
Last Name:KHEM
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 1:2348 GARETH CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3485
Mailing Address - Country:US
Mailing Address - Phone:209-684-3394
Mailing Address - Fax:
Practice Address - Street 1:3830 ALVARADO AVE
Practice Address - Street 2:STE. C
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-2330
Practice Address - Country:US
Practice Address - Phone:209-944-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health