Provider Demographics
NPI:1790955516
Name:FONG, KRISTEN E (MFT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:E
Last Name:FONG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 NORTHGATE DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2526
Mailing Address - Country:US
Mailing Address - Phone:415-250-0541
Mailing Address - Fax:
Practice Address - Street 1:1050 NORTHGATE DR
Practice Address - Street 2:SUITE 12
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2526
Practice Address - Country:US
Practice Address - Phone:415-250-0541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36228305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization