Provider Demographics
NPI:1700396983
Name:CHAN, SAM LEUNG-SANG (LCSW-C)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:LEUNG-SANG
Last Name:CHAN
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E PRESTON ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-3969
Mailing Address - Country:US
Mailing Address - Phone:586-703-6328
Mailing Address - Fax:
Practice Address - Street 1:1447 YORK RD STE 802
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6017
Practice Address - Country:US
Practice Address - Phone:410-356-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty