Healthcare Provider Details

I. General information

NPI: 1093369878
Provider Name (Legal Business Name): CHANG LIU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 05/12/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3539 COLLEGE AVENUE
SAN DIEGO CA
92115
US

IV. Provider business mailing address

3539 COLLEGE AVENUE
SAN DIEGO CA
92115
US

V. Phone/Fax

Practice location:
  • Phone: 619-818-3788
  • Fax: 619-795-6906
Mailing address:
  • Phone: 619-818-3788
  • Fax: 619-795-6906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT151948
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: