Basic Information
Provider Information | |||||||||
NPI: | 1164064234 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TUNGKANAK | ||||||||
FirstName: | CRYSTAL | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCABA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8601 WAGON TRL | ||||||||
Address2: |   | ||||||||
City: | CROSSROADS | ||||||||
State: | TX | ||||||||
PostalCode: | 762272217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7575932568 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8720 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FRISCO | ||||||||
State: | TX | ||||||||
PostalCode: | 750333079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4698035655 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2019 | ||||||||
LastUpdateDate: | 10/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 0-19-10228 | 01 |   | BACB | OTHER |