Provider Demographics
NPI:1316224249
Name:CHUNG, SU YEON (OTR/L)
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:YEON
Last Name:CHUNG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RIVER DR S APT 2415
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-3730
Mailing Address - Country:US
Mailing Address - Phone:917-566-4610
Mailing Address - Fax:
Practice Address - Street 1:25 E 104TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4402
Practice Address - Country:US
Practice Address - Phone:917-566-4610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-06
Last Update Date:2011-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010611-1225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist