Basic Information
| Provider Information | |||||||||
| NPI: | 1679638837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTFIELD MING QUONG | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EMQ CHILDREN & FAMILY SERVICES ROBERT SANDERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 251 LLEWELLYN AVE | ||||||||
| Address2: | |||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950081940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083793790 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3411 ROCKY MOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951274853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083793790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAMPION | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIVISION DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4083793790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8382 | 01 | CA | UNICARE | OTHER | L-000223 | 01 | CA | SCC LOCATION CODE | OTHER |