Healthcare Provider Details

I. General information

NPI: 1194642181
Provider Name (Legal Business Name): CHAN SUP OH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEVIN OH

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 KENYON ST STE 101
SAN DIEGO CA
92110-5341
US

IV. Provider business mailing address

3555 KENYON ST STE 101
SAN DIEGO CA
92110-5341
US

V. Phone/Fax

Practice location:
  • Phone: 619-600-0683
  • Fax:
Mailing address:
  • Phone: 619-600-0683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSB94029498
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-539950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: