Provider Demographics
NPI:1013212372
Name:CHONG, CANY TAN
Entity Type:Individual
Prefix:
First Name:CANY
Middle Name:TAN
Last Name:CHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:SIU
Other - Last Name:CHONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3330 N CENTRE LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761
Mailing Address - Country:US
Mailing Address - Phone:925-466-0357
Mailing Address - Fax:
Practice Address - Street 1:3330 N CENTRE LAKE DR.
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761
Practice Address - Country:US
Practice Address - Phone:925-466-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96233101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7368OtherMEDICAL
CA7184OtherMEDICAL
CA7667OtherMEDICAL
CA7708OtherMEDICAL