Provider Demographics
NPI:1003674243
Name:YONGSATIRACHOT-TANNER, SAITHIP
Entity Type:Individual
Prefix:
First Name:SAITHIP
Middle Name:
Last Name:YONGSATIRACHOT-TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 LOMA LINDA CT NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9391
Mailing Address - Country:US
Mailing Address - Phone:616-236-9091
Mailing Address - Fax:
Practice Address - Street 1:7230 LOMA LINDA CT NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9391
Practice Address - Country:US
Practice Address - Phone:616-236-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician