Provider Demographics
NPI:1538691860
Name:CHAN, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:CHAN
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 1:25 MAIN ST
Mailing Address - Street 2:PO BOX 962
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01262
Mailing Address - Country:US
Mailing Address - Phone:413-931-5282
Mailing Address - Fax:413-298-4020
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01262
Practice Address - Country:US
Practice Address - Phone:413-931-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2877542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry