Healthcare Provider Details

I. General information

NPI: 1851086714
Provider Name (Legal Business Name): FANWEN KONG LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 PLEASANT ST # 1
LYNN MA
01901-1524
US

IV. Provider business mailing address

216 LANTERN RD APT 24
REVERE MA
02151-1237
US

V. Phone/Fax

Practice location:
  • Phone: 781-861-0890
  • Fax:
Mailing address:
  • Phone: 517-775-7307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10006075
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: