Provider Demographics
NPI:1023319621
Name:CHANG, MIKE JAE YOUNG (MA)
Entity type:Individual
Prefix:MR
First Name:MIKE
Middle Name:JAE YOUNG
Last Name:CHANG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 OAK MOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:SHADOW HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91040-1270
Mailing Address - Country:US
Mailing Address - Phone:213-505-6771
Mailing Address - Fax:
Practice Address - Street 1:1910 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-1220
Practice Address - Country:US
Practice Address - Phone:213-342-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMF86321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007300Medicaid
CA00007782Medicaid