Provider Demographics
NPI:1962749077
Name:CHONG-SAULSBURY, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:CHONG-SAULSBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:MOON
Other - Last Name:CHONG-SAULSBURY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11911 CLOVER CREEK DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1219
Mailing Address - Country:US
Mailing Address - Phone:706-831-6775
Mailing Address - Fax:
Practice Address - Street 1:11911 CLOVER CREEK DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1219
Practice Address - Country:US
Practice Address - Phone:706-831-6775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60321586174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist