Provider Demographics
NPI:1811944317
Name:CHEUNG, CONNIE (DPT, MPH, RD/LD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CHEUNG
Suffix:
Gender:F
Credentials:DPT, MPH, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:13075 HIGHWAY 9 N STE 120
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-5147
Practice Address - Country:US
Practice Address - Phone:678-225-6861
Practice Address - Fax:678-944-9563
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002682133V00000X
GAPT007815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G708167OtherPTAN
GAQ26384Medicare UPIN