Healthcare Provider Details

I. General information

NPI: 1164908489
Provider Name (Legal Business Name): KE XIN CHONG CT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 330-793-2487
  • Fax: 330-743-5748
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-577-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1801062-TRNE
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61025601
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: