Provider Demographics
NPI:1316114077
Name:CHUNG, MISTY CALLANAN (MSW)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:CALLANAN
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2404
Mailing Address - Country:US
Mailing Address - Phone:810-496-5773
Mailing Address - Fax:810-496-5798
Practice Address - Street 1:422 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2404
Practice Address - Country:US
Practice Address - Phone:810-496-5773
Practice Address - Fax:810-496-5798
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085369101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health