Provider Demographics
NPI:1023424546
Name:CHUNG, MAI XUAN (MA ED)
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:XUAN
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MA ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 CABRILLO LN
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-5419
Mailing Address - Country:US
Mailing Address - Phone:866-936-7838
Mailing Address - Fax:866-936-7840
Practice Address - Street 1:46 UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-3306
Practice Address - Country:US
Practice Address - Phone:510-815-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171400000X
CABCBA 1-14-15228103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171400000XOther Service ProvidersHealth & Wellness Coach