Provider Demographics
NPI:1285857086
Name:FONG, COLLEEN (MA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BLANKEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-2407
Mailing Address - Country:US
Mailing Address - Phone:415-657-1770
Mailing Address - Fax:
Practice Address - Street 1:100 BLANKEN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-2407
Practice Address - Country:US
Practice Address - Phone:415-657-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52406106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist