Provider Demographics
NPI:1649876764
Name:CHANTHAVONG, KATELYNNE (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:KATELYNNE
Middle Name:
Last Name:CHANTHAVONG
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25335 119TH PL SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-6646
Mailing Address - Country:US
Mailing Address - Phone:425-802-9336
Mailing Address - Fax:
Practice Address - Street 1:110 2ND ST SW STE 140
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-5203
Practice Address - Country:US
Practice Address - Phone:425-802-9336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WAAB61182370106E00000X
WABACB593119103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst