Provider Demographics
NPI:1639791098
Name:BOONNOPPORNKUL, SOONTHORN (BCBA)
Entity Type:Individual
Prefix:
First Name:SOONTHORN
Middle Name:
Last Name:BOONNOPPORNKUL
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:BOONNOPPORNKUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:6160 CORNERSTONE CT E STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3724
Mailing Address - Country:US
Mailing Address - Phone:851-216-8837
Mailing Address - Fax:619-941-0276
Practice Address - Street 1:611 N BRAND BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3240
Practice Address - Country:US
Practice Address - Phone:747-286-2600
Practice Address - Fax:747-204-0181
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-65924103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst