Healthcare Provider Details

I. General information

NPI: 1023710324
Provider Name (Legal Business Name): KELLY DANIELLE GONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3518 JEFFERSON AVE
REDWOOD CITY CA
94062-3136
US

IV. Provider business mailing address

3518 JEFFERSON AVE
REDWOOD CITY CA
94062-3136
US

V. Phone/Fax

Practice location:
  • Phone: 650-365-7500
  • Fax: 650-365-7557
Mailing address:
  • Phone: 650-365-7500
  • Fax: 650-365-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: