Healthcare Provider Details

I. General information

NPI: 1740573237
Provider Name (Legal Business Name): PEGGY YI SHAN CHANG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: YI SHAN CHANG

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18623 GALE AVE
CITY OF INDUSTRY CA
91748-1342
US

IV. Provider business mailing address

106 E SANTONA CT
LA HABRA CA
90631-9261
US

V. Phone/Fax

Practice location:
  • Phone: 626-839-0300
  • Fax:
Mailing address:
  • Phone: 909-569-3841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number85513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: