Provider Demographics
NPI:1255756839
Name:VIKITSRETH, TANAPOL
Entity type:Individual
Prefix:
First Name:TANAPOL
Middle Name:
Last Name:VIKITSRETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NADHA/ NAT
Other - Middle Name:
Other - Last Name:VIKITSRETH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:700 S GREGORY ST APT 501
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-3785
Mailing Address - Country:US
Mailing Address - Phone:217-898-0595
Mailing Address - Fax:
Practice Address - Street 1:700 S GREGORY ST APT 501
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-3785
Practice Address - Country:US
Practice Address - Phone:217-898-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist