Provider Demographics
NPI:1740312834
Name:CHUNG, MIMI (ACSW)
Entity type:Individual
Prefix:MISS
First Name:MIMI
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 KELTON AVE APT 113
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2029
Mailing Address - Country:US
Mailing Address - Phone:323-578-2617
Mailing Address - Fax:
Practice Address - Street 1:1000 GOODRICH BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-5103
Practice Address - Country:US
Practice Address - Phone:323-832-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20148104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAENK1858OtherLA DEPT MENTAL HEALTH