Healthcare Provider Details

I. General information

NPI: 1144895210
Provider Name (Legal Business Name): HAILEY BOURGEAU CHANG PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 LEOPARD RD STE 304
PAOLI PA
19301-1549
US

IV. Provider business mailing address

126 CRICKET DR
MALVERN PA
19355-1547
US

V. Phone/Fax

Practice location:
  • Phone: 610-647-6406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS-019165
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: