Healthcare Provider Details

I. General information

NPI: 1295263473
Provider Name (Legal Business Name): BRIAN MICHAEL GONG LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 LINTON BLVD SUITE 200-A
DELRAY BEACH FL
33444
US

IV. Provider business mailing address

401 LINTON BLVD SUITE 200-A
DELRAY BEACH FL
33444
US

V. Phone/Fax

Practice location:
  • Phone: 561-501-1008
  • Fax: 561-431-2608
Mailing address:
  • Phone: 561-501-1008
  • Fax: 561-431-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH14460
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC7820
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: