Basic Information
| Provider Information | |||||||||
| NPI: | 1033250568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUKUMOTO | ||||||||
| FirstName: | EVA | ||||||||
| MiddleName: | SHANCHING | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEUNG | ||||||||
| OtherFirstName: | SHAN CHING | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12440 IMPERIAL HWY STE 116 | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906508347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008547771 | ||||||||
| FaxNumber: | 5628684609 | ||||||||
| Practice Location | |||||||||
| Address1: | 12440 IMPERIAL HWY STE 116 | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906508347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008547771 | ||||||||
| FaxNumber: | 5628684609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 01/16/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS 25497 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.