Provider Demographics
NPI:1205600236
Name:RATCHATAPONGSIRI, PHRAETAWAN
Entity type:Individual
Prefix:
First Name:PHRAETAWAN
Middle Name:
Last Name:RATCHATAPONGSIRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:
Other - Last Name:RATCHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13326 COMMUNITY RD APT 30
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-4736
Mailing Address - Country:US
Mailing Address - Phone:760-666-0442
Mailing Address - Fax:
Practice Address - Street 1:424 PENINSULA AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1653
Practice Address - Country:US
Practice Address - Phone:650-286-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician