Provider Demographics
NPI:1083955835
Name:PONGRAPHAN, BRYANNA NICOLE (BCABA)
Entity Type:Individual
Prefix:MS
First Name:BRYANNA
Middle Name:NICOLE
Last Name:PONGRAPHAN
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MERIDIAN DR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2696
Mailing Address - Country:US
Mailing Address - Phone:949-350-3811
Mailing Address - Fax:
Practice Address - Street 1:12443 LEWIS ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4650
Practice Address - Country:US
Practice Address - Phone:714-748-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-13-5266103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst