Provider Demographics
NPI:1881561488
Name:SONG, JOON (CMT)
Entity type:Individual
Prefix:MR
First Name:JOON
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 E CALIFORNIA BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3644
Mailing Address - Country:US
Mailing Address - Phone:510-435-1897
Mailing Address - Fax:
Practice Address - Street 1:6708 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-2743
Practice Address - Country:US
Practice Address - Phone:818-951-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99041225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty