Provider Demographics
NPI:1013519768
Name:SIRISUKARN, KALVIN K
Entity Type:Individual
Prefix:
First Name:KALVIN
Middle Name:K
Last Name:SIRISUKARN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5653 N. FRESNO ST.
Mailing Address - Street 2:105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:5653 N. FRESNO ST.
Practice Address - Street 2:105
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician