Basic Information
| Provider Information | |||||||||
| NPI: | 1639261761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEUNG | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5770 S 1500 W | ||||||||
| Address2: | #G | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013137770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5770 S 1500 W | ||||||||
| Address2: | #G | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013137770 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 02/06/2012 | ||||||||
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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 | 1041C0700X | 16500 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 544171400 | 05 | MN | MEDICAID |