Provider Demographics
NPI:1972238582
Name:CHUNG, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6041 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-8596
Mailing Address - Country:US
Mailing Address - Phone:503-676-7364
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5104
Practice Address - Country:US
Practice Address - Phone:866-523-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician