Healthcare Provider Details

I. General information

NPI: 1407406325
Provider Name (Legal Business Name): BRIGITTE FONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20695 S WESTERN AVE STE 132
TORRANCE CA
90501-1834
US

IV. Provider business mailing address

PO BOX 78175
LOS ANGELES CA
90016-0175
US

V. Phone/Fax

Practice location:
  • Phone: 424-271-7414
  • Fax:
Mailing address:
  • Phone: 323-632-7826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC10817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: