Healthcare Provider Details

I. General information

NPI: 1205182995
Provider Name (Legal Business Name): VINCENT FONG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 STOCKTON BLVD STE 3110
SACRAMENTO CA
95817-2207
US

IV. Provider business mailing address

2521 STOCKTON BLVD STE 3110
SACRAMENTO CA
95817-2207
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-1665
  • Fax: 916-734-4958
Mailing address:
  • Phone: 916-734-1665
  • Fax: 916-734-4958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS25019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: