Provider Demographics
NPI:1740030097
Name:CHAN, GEORGIA
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W 24TH ST APT 18N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1933
Mailing Address - Country:US
Mailing Address - Phone:310-299-6389
Mailing Address - Fax:
Practice Address - Street 1:733 3RD AVE FL 16
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-3224
Practice Address - Country:US
Practice Address - Phone:646-450-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health