MEDICARE: THU CHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst	0167104	CA

General Provider Information

NPI Number	:	1831610781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THU CHAN

Provider Business Mailing Address
First Line	:	PO BOX 5157
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95352-5157
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9355 E STOCKTON BLVD STE 100
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95624-9476
Country	:	US
Telephone Number	:	916-683-1109
Fax Number	:	916-683-1140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2017
Last Update Date	:	03/04/2019

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Directions to “ THU CHAN ” Practice Location

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