MEDICARE: CHRISTINA SOUVANNARATH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1679150023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA SOUVANNARATH

Provider Business Mailing Address
First Line	:	18726 S WESTERN AVE STE 408
Second Line	:
City	:	GARDENA
State	:	CA
Zip	:	90248-3858
Country	:	US
Telephone Number	:	310-856-0800
Fax Number	:	855-568-2494

Provider Business Practice Location Address
First Line	:	7777 BONHOMME AVE
Second Line	:
City	:	CLAYTON
State	:	MO
Zip	:	63105-1911
Country	:	US
Telephone Number	:	636-202-0693
Fax Number	:	855-568-2494

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2021
Last Update Date	:	07/08/2021

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Directions to “ CHRISTINA SOUVANNARATH ” Practice Location

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