| Doctor Name: | MR. ANDREW KEODARA PHOMTHAVONG |
| NPI Number: | 1003110990 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MSW |
| License Number: | |
| Business Practice Address: | 298 Walker Street Lowell, MA - 01851 |
| Business Phone Number: | 6197439052 |
| Business Fax Number: | |
| Mailing Address: | 298 Walker St, LOWELL |
| State: | MA |
| Postal Code: | 018511848 |
| Phone Number: | 6197439052 |
| Fax Number: | |
| NPI Enumeration Date: | 01/06/2011 |
| NPI Last Update Date: | 01/06/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |