Healthcare Provider Details

I. General information

NPI: 1932868668
Provider Name (Legal Business Name): CHANTANA VORNVILAIPAN AA, CERTIFICATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/28/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 WILLOW PASS RD STE 100
CONCORD CA
94520-7946
US

IV. Provider business mailing address

1430 WILLOW PASS RD STE 100
CONCORD CA
94520-7946
US

V. Phone/Fax

Practice location:
  • Phone: 925-288-3900
  • Fax: 925-646-5774
Mailing address:
  • Phone: 925-288-3900
  • Fax: 925-646-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: