Healthcare Provider Details

I. General information

NPI: 1366412108
Provider Name (Legal Business Name): GEOFFREY CHUNG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 11/09/2023
Certification Date: 11/08/2023
Deactivation Date: 05/15/2021
Reactivation Date: 01/07/2022

III. Provider practice location address

86 MDG, UNIT 3215 RAMSTEIN AB
APO AE
09094
US

IV. Provider business mailing address

86 MDG, UNIT 3215 RAMSTEIN AB
APO AE
09094
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 683
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: