Provider Demographics
NPI:1942941091
Name:KONSUE, KANYARAT
Entity Type:Individual
Prefix:
First Name:KANYARAT
Middle Name:
Last Name:KONSUE
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 1:13260 WINGO ST
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-4734
Mailing Address - Country:US
Mailing Address - Phone:818-633-1230
Mailing Address - Fax:
Practice Address - Street 1:8349 RESEDA BLVD STE F
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-5913
Practice Address - Country:US
Practice Address - Phone:818-341-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty