Provider Demographics
NPI:1205425337
Name:CHUNG, KLANCY J (REGISTERED AMFT)
Entity type:Individual
Prefix:
First Name:KLANCY
Middle Name:J
Last Name:CHUNG
Suffix:
Gender:F
Credentials:REGISTERED AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 RAYMELL DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5755 OBERLIN DR STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4715
Practice Address - Country:US
Practice Address - Phone:619-736-0436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA812817163W00000X
CA133954106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse