Provider Demographics
NPI:1629672688
Name:SRISOUVANH, EMILY ROSE
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:ROSE
Last Name:SRISOUVANH
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 1:795 ROCK ROSE CT
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-5772
Mailing Address - Country:US
Mailing Address - Phone:510-846-5602
Mailing Address - Fax:
Practice Address - Street 1:39159 PASEO PADRE PKWY STE 205
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1623
Practice Address - Country:US
Practice Address - Phone:510-730-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician