Healthcare Provider Details

I. General information

NPI: 1205425337
Provider Name (Legal Business Name): KLANCY J CHUNG REGISTERED AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 07/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 OBERLIN DR STE 106
SAN DIEGO CA
92121-4715
US

IV. Provider business mailing address

2530 RAYMELL DR
SAN DIEGO CA
92123-3544
US

V. Phone/Fax

Practice location:
  • Phone: 619-736-0436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number133954
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number812817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: