Healthcare Provider Details

I. General information

NPI: 1639237217
Provider Name (Legal Business Name): GRACE WING MAN FONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

725 WELCH RD
PALO ALTO CA
94304-1601
US

V. Phone/Fax

Practice location:
  • Phone: 650-497-8000
  • Fax:
Mailing address:
  • Phone: 650-497-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36249
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY36249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: