Healthcare Provider Details

I. General information

NPI: 1285198325
Provider Name (Legal Business Name): SYDNEY PHONGSIRIKUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 ATLANTIC AVE STE 101
ALAMEDA CA
94501-1188
US

IV. Provider business mailing address

991 37TH ST
RICHMOND CA
94805-1318
US

V. Phone/Fax

Practice location:
  • Phone: 510-268-2120
  • Fax: 510-251-8120
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: