Provider Demographics
NPI:1235720194
Name:LO, CHEENOU (CBT)
Entity Type:Individual
Prefix:
First Name:CHEENOU
Middle Name:
Last Name:LO
Suffix:
Gender:M
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 EL CAMINO AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-6553
Mailing Address - Country:US
Mailing Address - Phone:828-781-8819
Mailing Address - Fax:
Practice Address - Street 1:2150 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1337
Practice Address - Country:US
Practice Address - Phone:828-781-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2023-01-14
Deactivation Date:2021-06-02
Deactivation Code:
Reactivation Date:2021-07-09
Provider Licenses
StateLicense IDTaxonomies
WACB61077541106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician