Provider Demographics
NPI:1164064234
Name:TUNGKANAK, CRYSTAL LEIGH (BCABA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEIGH
Last Name:TUNGKANAK
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 1:8601 WAGON TRL
Mailing Address - Street 2:
Mailing Address - City:CROSSROADS
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2217
Mailing Address - Country:US
Mailing Address - Phone:757-593-2568
Mailing Address - Fax:
Practice Address - Street 1:8720 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3079
Practice Address - Country:US
Practice Address - Phone:469-803-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-19-10228OtherBACB