=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114315173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESTER COUNTY WELL-BEING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2014
-----------------------------------------------------
Last Update Date | 12/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 ORCHARD AVE SUITE C101
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-530-1419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 NEWFIELD CT
-----------------------------------------------------
City | WEST GROVE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19390-8942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-530-1419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | MALYNN KUANGPARICHAT
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 302-530-1419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | PS017132
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------