Provider Demographics
NPI:1508344789
Name:SISOMPHOU, DEVIN (BCBA, MED, LBA)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:
Last Name:SISOMPHOU
Suffix:
Gender:F
Credentials:BCBA, MED, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 PREMIER DR STE 234
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2693
Mailing Address - Country:US
Mailing Address - Phone:806-993-3333
Mailing Address - Fax:
Practice Address - Street 1:6102 82ND ST STE 10
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424
Practice Address - Country:US
Practice Address - Phone:806-993-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-33360247200000X
TX3032103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-17-33360OtherBACB
TX3032OtherTEXAS DEPARTMENT OF LICENSING & REGULATION