Healthcare Provider Details

I. General information

NPI: 1922546084
Provider Name (Legal Business Name): KRYSTAL HONG LAM B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 W ORANGEWOOD AVE STE 110
ORANGE CA
92868-5056
US

IV. Provider business mailing address

1820 W ORANGEWOOD AVE STE 110
ORANGE CA
92868-5056
US

V. Phone/Fax

Practice location:
  • Phone: 714-696-2862
  • Fax: 714-242-9308
Mailing address:
  • Phone: 714-696-2862
  • Fax: 714-242-9308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35884
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: