Provider Demographics
NPI:1962024034
Name:SONG, CHAO (PHD)
Entity Type:Individual
Prefix:
First Name:CHAO
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 MANSFIELD RD UNIT 1255
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06269-9000
Mailing Address - Country:US
Mailing Address - Phone:860-486-4705
Mailing Address - Fax:860-486-9159
Practice Address - Street 1:377 MANSFIELD RD UNIT 1255
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06269-9000
Practice Address - Country:US
Practice Address - Phone:860-486-4705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3931103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical