Basic Information
| Provider Information | |||||||||
| NPI: | 1437398989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAE | ||||||||
| FirstName: | MI JUNG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAE | ||||||||
| OtherFirstName: | MI | ||||||||
| OtherMiddleName: | JUNG | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 SCOFIELD AVE | ||||||||
| Address2: | P.O. BOX 8800 | ||||||||
| City: | WASCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932807515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617588400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 SCOFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WASCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932807515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617588400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2009 | ||||||||
| LastUpdateDate: | 02/06/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY19327 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.