Healthcare Provider Details

I. General information

NPI: 1154730240
Provider Name (Legal Business Name): LINDA ANANDA FONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 MILVIA ST
BERKELEY CA
94704
US

IV. Provider business mailing address

PO BOX 7683
BERKELEY CA
94707-0683
US

V. Phone/Fax

Practice location:
  • Phone: 510-926-6812
  • Fax:
Mailing address:
  • Phone: 510-926-6812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number86731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: