Healthcare Provider Details

I. General information

NPI: 1316529647
Provider Name (Legal Business Name): KRISTEN ANN CHEUNG LCSW, CT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FERN AVE
PENNGROVE CA
94951-8674
US

IV. Provider business mailing address

PO BOX 2573
PETALUMA CA
94953-2573
US

V. Phone/Fax

Practice location:
  • Phone: 707-780-2120
  • Fax:
Mailing address:
  • Phone: 707-780-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number96901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: