Provider Demographics
NPI:1124040720
Name:KOO, DONG HWAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DONG
Middle Name:HWAN
Last Name:KOO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10929 SOUTH ST
Mailing Address - Street 2:STE 202B
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-5340
Mailing Address - Country:US
Mailing Address - Phone:562-569-5580
Mailing Address - Fax:562-776-9496
Practice Address - Street 1:10929 SOUTH ST
Practice Address - Street 2:STE 202B
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-5340
Practice Address - Country:US
Practice Address - Phone:562-569-5580
Practice Address - Fax:562-776-9496
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19860103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent