Healthcare Provider Details

I. General information

NPI: 1790409332
Provider Name (Legal Business Name): ANDY HUANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

PO BOX 639561
CINCINNATI OH
45263-9561
US

V. Phone/Fax

Practice location:
  • Phone: 844-442-9022
  • Fax: 215-489-8766
Mailing address:
  • Phone: 844-247-7222
  • Fax: 215-489-8766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-234542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: