Provider Demographics
NPI:1386875219
Name:CHAN, VIVIAN LEE (PSYD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:LEE
Last Name:CHAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:
Other - Last Name:LEE-CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1145 GAYLEY AVE STE 322
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3415
Mailing Address - Country:US
Mailing Address - Phone:310-208-7187
Mailing Address - Fax:
Practice Address - Street 1:1145 GAYLEY AVE STE 322
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3415
Practice Address - Country:US
Practice Address - Phone:310-208-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 48328390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program