Provider Demographics
NPI:1417548173
Name:KONG, STEVEN MICHAEL (MS, ATC)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MICHAEL
Last Name:KONG
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:886 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0110
Mailing Address - Country:US
Mailing Address - Phone:408-410-6056
Mailing Address - Fax:
Practice Address - Street 1:1700 W HILLSDALE BLVD BLDG 30A
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3757
Practice Address - Country:US
Practice Address - Phone:650-574-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0807022672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer