Provider Demographics
NPI:1356590632
Name:CHANG, CHANDLER SIMS (PHD)
Entity type:Individual
Prefix:DR
First Name:CHANDLER
Middle Name:SIMS
Last Name:CHANG
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:323-455-8080
Mailing Address - Fax:
Practice Address - Street 1:250 E 1ST ST
Practice Address - Street 2:SUITE 1201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3811
Practice Address - Country:US
Practice Address - Phone:323-455-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY220920Medicaid
CACY803ZMedicare PIN