Provider Demographics
NPI:1912749730
Name:CHANG, SEOUNGYEUN
Entity type:Individual
Prefix:MR
First Name:SEOUNGYEUN
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COPPERBEECH RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2128
Mailing Address - Country:US
Mailing Address - Phone:631-575-8122
Mailing Address - Fax:
Practice Address - Street 1:3249 KINGSBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5514
Practice Address - Country:US
Practice Address - Phone:164-620-4229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health