Provider Demographics
NPI:1811213432
Name:CHANG, KYUNG (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KYUNG
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MINA
Other - Middle Name:KYUNG
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3901 MAIN ST
Mailing Address - Street 2:#508
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5432
Mailing Address - Country:US
Mailing Address - Phone:201-313-3346
Mailing Address - Fax:718-888-1876
Practice Address - Street 1:581 BERGEN BLVD
Practice Address - Street 2:#4
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-2030
Practice Address - Country:US
Practice Address - Phone:201-313-3346
Practice Address - Fax:718-888-1876
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR032790-1101YA0400X, 101YM0800X, 1041C0700X, 1041S0200X, 106H00000X
NJ44SC05237500101YA0400X, 101YM0800X, 1041C0700X, 1041S0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist