Provider Demographics
NPI:1508021270
Name:KONG, ANISA CHUN (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:ANISA
Middle Name:CHUN
Last Name:KONG
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 E FRANKLIN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4983
Mailing Address - Country:US
Mailing Address - Phone:704-830-6168
Mailing Address - Fax:704-853-1809
Practice Address - Street 1:2230 E FRANKLIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4983
Practice Address - Country:US
Practice Address - Phone:704-830-6168
Practice Address - Fax:704-853-1809
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC888225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG56017Medicaid