Provider Demographics
NPI:1770031080
Name:CHHUN, MARDY
Entity Type:Individual
Prefix:
First Name:MARDY
Middle Name:
Last Name:CHHUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARDY
Other - Middle Name:
Other - Last Name:NEANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9465 FARNHAM ST # 92123
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1308
Mailing Address - Country:US
Mailing Address - Phone:858-573-2600
Mailing Address - Fax:
Practice Address - Street 1:4283 EL CAJON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1289
Practice Address - Country:US
Practice Address - Phone:619-521-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 175T00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator