Provider Demographics
NPI:1033863907
Name:CHUNG, MIA GABRIELLE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:GABRIELLE
Last Name:CHUNG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 OLEANDER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6841
Mailing Address - Country:US
Mailing Address - Phone:910-660-8045
Mailing Address - Fax:
Practice Address - Street 1:4010 OLEANDER DR STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6841
Practice Address - Country:US
Practice Address - Phone:910-660-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21214101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health