Provider Demographics
NPI:1093231938
Name:SUN, CONNIE (BCBA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:SUN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 E LIVE OAK AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5252
Mailing Address - Country:US
Mailing Address - Phone:626-226-9023
Mailing Address - Fax:
Practice Address - Street 1:159 E LIVE OAK AVE STE 206
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5252
Practice Address - Country:US
Practice Address - Phone:626-226-9023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-17292103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty