Provider Demographics
NPI:1164969986
Name:DUONG, CONNIE TIEU (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:TIEU
Last Name:DUONG
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 OCEAN VIEW BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1438
Mailing Address - Country:US
Mailing Address - Phone:818-937-0882
Mailing Address - Fax:818-937-0883
Practice Address - Street 1:4515 OCEAN VIEW BLVD STE 320
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-1438
Practice Address - Country:US
Practice Address - Phone:818-937-0882
Practice Address - Fax:818-937-0883
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-28387103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst