Provider Demographics
NPI:1134744774
Name:GONG, CORY MASON
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:MASON
Last Name:GONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N WINCHESTER BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 N WINCHESTER BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1150
Practice Address - Country:US
Practice Address - Phone:650-380-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4493272106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician