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General NPI Number Information
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NPI Number | 1528507084
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Entity Type | Organization
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Legal Business Name | DOCTOR TLC, LICENSE CLINICAL PSYCHOLOGIST, INC.
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Dates
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Enumeration Date | 02/16/2017
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Last Update Date | 07/17/2019
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Provider Practice Location Address
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Address Line | 1242 THIRD ST PROMENADE, SUITE 208
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City | SANTA MONICA
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State | CA
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Zip | 90401
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Country | US
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Telephone | 201-406-9496
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Fax |
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Provider Business Mailing Address
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Address Line | 1242 THIRD ST PROMENADE, SUITE 208
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City | SANTA MONICA
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State | CA
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Zip | 90401
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Country | US
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Telephone | 201-406-9496
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. TERESA LIAW CHUNG
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Credential | PSY.D.
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Telephone | 424-272-5233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | PSY27669
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License Number State | CA
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