Healthcare Provider Details

I. General information

NPI: 1649876764
Provider Name (Legal Business Name): KATELYNNE CHANTHAVONG M.A., BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2020
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 2ND ST SW STE 140
AUBURN WA
98001-5203
US

IV. Provider business mailing address

25335 119TH PL SE
KENT WA
98030-6646
US

V. Phone/Fax

Practice location:
  • Phone: 425-802-9336
  • Fax:
Mailing address:
  • Phone: 425-802-9336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB593119
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberAB61182370
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: