Provider Demographics
NPI:1538559166
Name:TANYAVUTTI, JUSTIN SURACHAI (LPCC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SURACHAI
Last Name:TANYAVUTTI
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2543
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-0543
Mailing Address - Country:US
Mailing Address - Phone:847-422-3654
Mailing Address - Fax:
Practice Address - Street 1:1918 BONITA AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:703-261-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010560101YP2500X
CALPCC6651101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional