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General NPI Number Information
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NPI Number | 1295263473
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Entity Type | Individual
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Provider Name | BRIAN MICHAEL GONG LMHC
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Gender | Male
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Dates
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Enumeration Date | 05/31/2017
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 401 LINTON BLVD SUITE 200-A
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City | DELRAY BEACH
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State | FL
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Zip | 33444
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Country | US
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Telephone | 561-501-1008
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Fax | 561-431-2608
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Provider Business Mailing Address
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Address Line | 401 LINTON BLVD SUITE 200-A
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City | DELRAY BEACH
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State | FL
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Zip | 33444
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Country | US
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Telephone | 561-501-1008
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Fax | 561-431-2608
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH14460
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC7820
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License Number State | MD
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