Healthcare Provider Details

I. General information

NPI: 1780928549
Provider Name (Legal Business Name): CHONG CONCANNON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MONTAUK CT
PARKVILLE MD
21234-1351
US

IV. Provider business mailing address

18 MONTAUK CT
PARKVILLE MD
21234-1351
US

V. Phone/Fax

Practice location:
  • Phone: 410-343-9008
  • Fax:
Mailing address:
  • Phone: 410-343-9008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC4759
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: