Healthcare Provider Details

I. General information

NPI: 1063123347
Provider Name (Legal Business Name): KANCHAN CHUGANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

951 S BEACH BLVD UNIT H1064H
LA HABRA CA
90631-1648
US

V. Phone/Fax

Practice location:
  • Phone: 909-576-1113
  • Fax:
Mailing address:
  • Phone: 909-576-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number111404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: