Provider Demographics
NPI:1093087181
Name:INTARACHOTE VAN ETTEN, NISSA
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:
Last Name:INTARACHOTE VAN ETTEN
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 1:311 LENNON LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2418
Mailing Address - Country:US
Mailing Address - Phone:925-210-9370
Mailing Address - Fax:925-210-0436
Practice Address - Street 1:311 LENNON LN
Practice Address - Street 2:SUITE A
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2418
Practice Address - Country:US
Practice Address - Phone:925-210-9370
Practice Address - Fax:925-210-0436
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1084077103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst