Healthcare Provider Details

I. General information

NPI: 1487109120
Provider Name (Legal Business Name): TRUNGTA KAE WERNER BEHAVIOR ANALYST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRUNGTA KOSITCHAIMONGKOL BS

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CARNEGIE AVE STE 1C
SANTA ANA CA
92705-5504
US

IV. Provider business mailing address

11037 WARNER AVE # 339
FOUNTAIN VALLEY CA
92708-4007
US

V. Phone/Fax

Practice location:
  • Phone: 800-273-4292
  • Fax: 714-596-6274
Mailing address:
  • Phone: 800-273-4292
  • Fax: 949-253-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-38043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: