=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649961459
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHASE AUSTIN GRIDER-MUNSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 354 CERNON ST
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95688-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-685-0899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 ALDER TREE WAY APT 161
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95831-3954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-945-4303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------