Provider Demographics
NPI:1720120215
Name:CHANG, TYNETTE (BCBA)
Entity Type:Individual
Prefix:
First Name:TYNETTE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:TYNETTE
Other - Middle Name:
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:PATUXENT RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20670-0237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5425 WISCONSIN AVE STE 600
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-3588
Practice Address - Country:US
Practice Address - Phone:202-780-8976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA317103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst