Healthcare Provider Details

I. General information

NPI: 1598284051
Provider Name (Legal Business Name): EVELYN KWONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 10/05/2024
Certification Date: 10/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4823 62ND ST
SACRAMENTO CA
95820-5717
US

IV. Provider business mailing address

630 BERCUT DR
SACRAMENTO CA
95811-0110
US

V. Phone/Fax

Practice location:
  • Phone: 916-203-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW89843
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110015
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: