Provider Demographics
NPI:1497942320
Name:CHAN, HIEDI M (MA)
Entity Type:Individual
Prefix:
First Name:HIEDI
Middle Name:M
Last Name:CHAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 CAMINO DEL RIO S STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3734
Mailing Address - Country:US
Mailing Address - Phone:858-945-4241
Mailing Address - Fax:
Practice Address - Street 1:13037 YERBA VALLEY WAY
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-1567
Practice Address - Country:US
Practice Address - Phone:858-945-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50813106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist