Provider Demographics
NPI:1104383090
Name:CHAN, STEPHANIE (BCBA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CHAN
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 1:583 SHOEMAKER RD STE 230
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4238
Mailing Address - Country:US
Mailing Address - Phone:484-681-2170
Mailing Address - Fax:
Practice Address - Street 1:7529 STANDISH PL STE 355
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20855-2733
Practice Address - Country:US
Practice Address - Phone:571-317-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-18-33778103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst