Provider Demographics
NPI:1124710686
Name:CHUOL, DAVID B
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:CHUOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:B
Other - Last Name:JOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1946 KEYHILL AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1946 KEYHILL AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4319
Practice Address - Country:US
Practice Address - Phone:616-334-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
J500135475643106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician