Provider Demographics
NPI:1619116050
Name:FONG, DOROTHEA P (LMT, NHD)
Entity Type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:P
Last Name:FONG
Suffix:
Gender:F
Credentials:LMT, NHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 PINE VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03086-5511
Mailing Address - Country:US
Mailing Address - Phone:603-654-9697
Mailing Address - Fax:
Practice Address - Street 1:43 MAIN STREET 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:NH
Practice Address - Zip Code:03086-5511
Practice Address - Country:US
Practice Address - Phone:603-654-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1370M225700000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service