MEDICARE: KATHERINE S GONG LCSW, DCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW 5450	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z062E	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1376631135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE S GONG LCSW, DCSW

Provider Business Mailing Address
First Line	:	PO BOX 371836
Second Line	:
City	:	KEY LARGO
State	:	FL
Zip	:	33037-1836
Country	:	US
Telephone Number	:	305-394-4006
Fax Number	:	305-451-2816

Provider Business Practice Location Address
First Line	:	103400 OVERSEAS HWY
Second Line	:	SUITE 201/202
City	:	KEY LARGO
State	:	FL
Zip	:	33037-2834
Country	:	US
Telephone Number	:	305-394-4006
Fax Number	:	305-451-2816

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	05/21/2009

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