Healthcare Provider Details

I. General information

NPI: 1235720194
Provider Name (Legal Business Name): CHEENOU LO CBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 01/14/2023
Certification Date: 01/14/2023
Deactivation Date: 06/02/2021
Reactivation Date: 07/09/2021

III. Provider practice location address

2150 STOCKTON BLVD
SACRAMENTO CA
95817-1337
US

IV. Provider business mailing address

3629 EL CAMINO AVE
SACRAMENTO CA
95821-6553
US

V. Phone/Fax

Practice location:
  • Phone: 828-781-8819
  • Fax:
Mailing address:
  • Phone: 828-781-8819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61077541
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: