Provider Demographics
NPI:1629855598
Name:KONG, MICAELA
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 7TH AVE
Mailing Address - Street 2:STE. 801
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:646-418-1172
Mailing Address - Fax:
Practice Address - Street 1:352 7TH AVE
Practice Address - Street 2:STE. 801
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:646-418-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P124698-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health