Provider Demographics
NPI:1104407915
Name:CHANTHABANDITH, CHRIS (OTR/L)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:CHANTHABANDITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11825 N 25TH PL APT 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6500
Mailing Address - Country:US
Mailing Address - Phone:616-635-9722
Mailing Address - Fax:
Practice Address - Street 1:17100 E SHEA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6663
Practice Address - Country:US
Practice Address - Phone:480-837-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist