Provider Demographics
NPI:1215570007
Name:CHUNG, GRACE E
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:CHUNG
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 1:7336 EL DOMINO WAY APT 2
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2637
Mailing Address - Country:US
Mailing Address - Phone:714-356-2132
Mailing Address - Fax:
Practice Address - Street 1:7336 EL DOMINO WAY APT 2
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-2637
Practice Address - Country:US
Practice Address - Phone:714-356-2132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT20066225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist