Provider Demographics
NPI:1295374718
Name:DER, JUSTIN CHONG (LPC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CHONG
Last Name:DER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11409 MARTY ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2643
Mailing Address - Country:US
Mailing Address - Phone:913-360-0929
Mailing Address - Fax:
Practice Address - Street 1:14221 METCALF AVE STE 130
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-3301
Practice Address - Country:US
Practice Address - Phone:913-214-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-01
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2959101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201324710AMedicaid