Provider Demographics
NPI:1205397213
Name:CHONG, PHYLLIS
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:CHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 N PEORIA ST APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5925
Mailing Address - Country:US
Mailing Address - Phone:312-545-5195
Mailing Address - Fax:
Practice Address - Street 1:689 N PEORIA ST APT 1S
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5925
Practice Address - Country:US
Practice Address - Phone:312-545-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490102951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical