Provider Demographics
NPI:1356706915
Name:VONG, MARYLYN (MSW)
Entity type:Individual
Prefix:MS
First Name:MARYLYN
Middle Name:
Last Name:VONG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 SANDSTONE ST
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-2456
Mailing Address - Country:US
Mailing Address - Phone:626-315-1217
Mailing Address - Fax:
Practice Address - Street 1:545 SANDSTONE ST
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2456
Practice Address - Country:US
Practice Address - Phone:626-315-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health