Provider Demographics
NPI:1295263473
Name:GONG, BRIAN MICHAEL (LMHC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GONG
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 LINTON BLVD
Mailing Address - Street 2:SUITE 200-A
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444
Mailing Address - Country:US
Mailing Address - Phone:561-501-1008
Mailing Address - Fax:561-431-2608
Practice Address - Street 1:401 LINTON BLVD
Practice Address - Street 2:SUITE 200-A
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444
Practice Address - Country:US
Practice Address - Phone:561-501-1008
Practice Address - Fax:561-431-2608
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14460101YM0800X
MDLC7820101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health