Provider Demographics
NPI:1518420132
Name:CHUNG, MICHELLE (BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 MUSTANG DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8640
Mailing Address - Country:US
Mailing Address - Phone:817-722-6118
Mailing Address - Fax:817-442-0223
Practice Address - Street 1:2401 MUSTANG DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8640
Practice Address - Country:US
Practice Address - Phone:817-722-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-19-82183106S00000X
TX1-20-46686103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician