Provider Demographics
NPI:1881036929
Name:FONG, REINA LORINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:REINA
Middle Name:LORINE
Last Name:FONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964-0216
Mailing Address - Country:US
Mailing Address - Phone:415-454-1460
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964-1000
Practice Address - Country:US
Practice Address - Phone:415-454-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18602103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical