Basic Information
| Provider Information | |||||||||
| NPI: | 1295158624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | I-TE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | CHEN | ||||||||
| OtherFirstName: | OLIVIA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5955 ZEAMER AVE | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995063702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105522486 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5955 ZEAMER AVE | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075805858 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2014 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 9764002-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.