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General NPI Number Information
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NPI Number | 1518366004
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Entity Type | Individual
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Provider Name | BRIAN KONG
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Gender | Male
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Dates
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Enumeration Date | 08/20/2014
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Last Update Date | 11/15/2019
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Provider Practice Location Address
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Address Line | 2001 W NORTH AVE
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City | CHICAGO
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State | IL
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Zip | 60647
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Country | US
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Telephone | 872-588-0220
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Fax |
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Provider Business Mailing Address
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Address Line | 1564 N DAMEN AVE STE 208
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City | CHICAGO
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State | IL
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Zip | 60622-2102
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Country | US
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Telephone | 872-588-9220
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Fax |
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071008677
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License Number State | IL
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