=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770847444
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YACHEN TERRI PENG BACB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2012
-----------------------------------------------------
Last Update Date | 06/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9060 HUNTINGTON DR
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91775-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-943-7772
-----------------------------------------------------
Fax | 626-943-7730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 HAMPTON RD
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91006-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-943-7772
-----------------------------------------------------
Fax | 626-943-7730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | OP112090
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------