Provider Demographics
NPI:1568943918
Name:CHENG, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:CHENG
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 1:2420 MARTIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8610
Mailing Address - Country:US
Mailing Address - Phone:707-399-4520
Mailing Address - Fax:707-399-4521
Practice Address - Street 1:2420 MARTIN RD STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-8610
Practice Address - Country:US
Practice Address - Phone:707-399-4520
Practice Address - Fax:707-399-4521
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5512101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health