Provider Demographics
NPI:1407331051
Name:CHANG XU, YEN SHU
Entity Type:Individual
Prefix:
First Name:YEN
Middle Name:SHU
Last Name:CHANG XU
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 1:114 ANDREW STILL CT APT 1082
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6346
Mailing Address - Country:US
Mailing Address - Phone:909-618-7008
Mailing Address - Fax:
Practice Address - Street 1:114 ANDREW STILL CT APT 1082
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6346
Practice Address - Country:US
Practice Address - Phone:909-618-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-18-65083106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician