Provider Demographics
NPI:1164977666
Name:LEONG, CHANNING (MPT)
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:
Last Name:LEONG
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5199 CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2115
Mailing Address - Country:US
Mailing Address - Phone:408-267-2779
Mailing Address - Fax:
Practice Address - Street 1:585 N MARY AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94085-2905
Practice Address - Country:US
Practice Address - Phone:408-481-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19829171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator