Healthcare Provider Details

I. General information

NPI: 1134538564
Provider Name (Legal Business Name): MICHELLE CHONG PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE HONG PSYD

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 CLUB CENTER DR
SAN BERNARDINO CA
92408-4170
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY30562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: