Provider Demographics
NPI:1598714727
Name:FAN, CHI (LMFT)
Entity Type:Individual
Prefix:MS
First Name:CHI
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:CHI
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:941 S. ATLANTIC BLVD,
Mailing Address - Street 2:SUITE 221
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4722
Mailing Address - Country:US
Mailing Address - Phone:626-284-4202
Mailing Address - Fax:626-284-3926
Practice Address - Street 1:941 S. ATLANTIC BLVD,
Practice Address - Street 2:SUITE 221
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4722
Practice Address - Country:US
Practice Address - Phone:626-284-4202
Practice Address - Fax:626-284-3926
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35165106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC35165OtherLICENSE NUMBER