Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103K00000X | Behavior Analyst | 1-04-1585 | FL |
Y | 102L00000X | Psychologist | 8214 | FL |
Y | 103T00000X | Psychologist | 8214 | FL |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 6301012869 | MI |
NPI | 1033306733 |
---|---|
Provider Name | Dr. Ivy Chong |
First Address | Melbourne, FL 32901-6982 |
Second Address | Melbourne, FL 32901-6982 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2007 |
Last Update Date | 11/07/2011 |