Healthcare Provider Details

I. General information

NPI: 1871074997
Provider Name (Legal Business Name): GRACE CHANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10653 RIVERSIDE DR
NORTH HOLLYWOOD CA
91602-2341
US

IV. Provider business mailing address

3183 WILSHIRE BLVD # 196D5
LOS ANGELES CA
90010-1211
US

V. Phone/Fax

Practice location:
  • Phone: 213-787-7644
  • Fax:
Mailing address:
  • Phone: 213-787-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31147
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: