Provider Demographics
NPI:1922145572
Name:CHONG, ROBERTO (LICSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:
Last Name:CHONG
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 CANAL ST
Mailing Address - Street 2:4TH FLOOR EAST
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1244
Mailing Address - Country:US
Mailing Address - Phone:978-857-1553
Mailing Address - Fax:978-346-8853
Practice Address - Street 1:599 CANAL ST
Practice Address - Street 2:4TH FLOOR EAST
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1244
Practice Address - Country:US
Practice Address - Phone:978-857-1553
Practice Address - Fax:978-346-8853
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1045571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P20386Medicare ID - Type UnspecifiedMEDICARE PROVIDER #