Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | 20131374 | TX |
NPI | 1003428178 |
---|---|
Provider Name | Chloe Vongphachanh |
First Address | Southlake, TX 76092-6674 |
Second Address | Southlake, TX 76092-6674 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2020 |
Last Update Date | 20/08/2020 |