Provider Demographics
NPI:1427783034
Name:CHONG, ELIYA JIWON
Entity type:Individual
Prefix:
First Name:ELIYA
Middle Name:JIWON
Last Name:CHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JIWON
Other - Middle Name:
Other - Last Name:CHOI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3551 CAMINO MIRA COSTA STE T
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3508
Mailing Address - Country:US
Mailing Address - Phone:949-272-4444
Mailing Address - Fax:949-272-4445
Practice Address - Street 1:3551 CAMINO MIRA COSTA STE T
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3508
Practice Address - Country:US
Practice Address - Phone:949-272-4444
Practice Address - Fax:949-272-4445
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2024-08-13
Deactivation Date:2023-04-06
Deactivation Code:
Reactivation Date:2023-04-26
Provider Licenses
StateLicense IDTaxonomies
CA148366106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist