Provider Demographics
NPI:1114051570
Name:FONG, DOUGLAS J (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:FONG
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1222
Mailing Address - Country:US
Mailing Address - Phone:650-556-6422
Mailing Address - Fax:650-349-0476
Practice Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1222
Practice Address - Country:US
Practice Address - Phone:650-556-6422
Practice Address - Fax:650-349-0476
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33984106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist