Provider Demographics
NPI:1508635186
Name:BOUKHALIL, VIVIAN CHARBEL
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:CHARBEL
Last Name:BOUKHALIL
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 1:713 W COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1612
Mailing Address - Country:US
Mailing Address - Phone:657-549-0489
Mailing Address - Fax:
Practice Address - Street 1:28620 EVENING BREEZE DR
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-6410
Practice Address - Country:US
Practice Address - Phone:657-549-0489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst