Provider Demographics
NPI:1336278993
Name:KONG, BOSSEBA (LCS 16696)
Entity Type:Individual
Prefix:
First Name:BOSSEBA
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:LCS 16696
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 KANSAS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-1596
Mailing Address - Country:US
Mailing Address - Phone:209-558-7475
Mailing Address - Fax:209-558-4042
Practice Address - Street 1:1100 KANSAS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-1596
Practice Address - Country:US
Practice Address - Phone:209-558-7475
Practice Address - Fax:209-558-4042
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical