Provider Demographics
NPI:1659027852
Name:CHAN, JUSTIN K
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:K
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15576 TETLEY ST
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-4502
Mailing Address - Country:US
Mailing Address - Phone:626-695-5812
Mailing Address - Fax:
Practice Address - Street 1:2211 W MAGNOLIA BLVD # 295
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1753
Practice Address - Country:US
Practice Address - Phone:818-955-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464040225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist