MEDICARE: NICOLA CHUNG, PH.D., LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY 7307	FL

General Provider Information

NPI Number	:	1346312923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLA CHUNG, PH.D., LLC

Provider Business Mailing Address
First Line	:	1021 IVES DAIRY RD
Second Line	:	SUITE 119
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-2537
Country	:	US
Telephone Number	:	305-490-8590
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 IVES DAIRY RD
Second Line	:	SUITE 119
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-2537
Country	:	US
Telephone Number	:	305-490-8590
Fax Number	:

Authorized Official
Title or Position	:	MGRM
Name	:	DR. NICOLA CHUNG
Credential	:	PH.D.
Telephone Number	:	305-490-8590

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	09/14/2013

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