Healthcare Provider Details

I. General information

NPI: 1134648231
Provider Name (Legal Business Name): MR. THEAR CHUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 LEVER BLVD
STOCKTON CA
95206-2855
US

IV. Provider business mailing address

1142 PONCE DE LEON AVE
STOCKTON CA
95209-2620
US

V. Phone/Fax

Practice location:
  • Phone: 209-479-3951
  • Fax:
Mailing address:
  • Phone: 209-242-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: