Provider Demographics
NPI:1093044455
Name:KONG, MARI EVONNE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:EVONNE
Last Name:KONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:EVONNE
Other - Last Name:KONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5301 E STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2388
Mailing Address - Country:US
Mailing Address - Phone:815-397-8500
Mailing Address - Fax:815-397-8588
Practice Address - Street 1:5301 E STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2388
Practice Address - Country:US
Practice Address - Phone:815-397-8500
Practice Address - Fax:815-397-8588
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0052131041C0700X
WI1605-1231041C0700X
WI612-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist