Provider Demographics
NPI:1366792442
Name:CHENG, JUSTIN ALVIN
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ALVIN
Last Name:CHENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 BAKER ST STE A
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4566
Mailing Address - Country:US
Mailing Address - Phone:714-361-6760
Mailing Address - Fax:
Practice Address - Street 1:275 BAKER ST STE A
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4566
Practice Address - Country:US
Practice Address - Phone:714-361-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA788221041C0700X, 1041C0700X, 1041C0700X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program