Healthcare Provider Details

I. General information

NPI: 1073382560
Provider Name (Legal Business Name): CHRISTINA FONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4304
US

IV. Provider business mailing address

56 MONROE CENTER ST NW APT 4
GRAND RAPIDS MI
49503-2937
US

V. Phone/Fax

Practice location:
  • Phone: 616-303-1313
  • Fax:
Mailing address:
  • Phone: 616-965-6696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451023383
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: