Provider Demographics
NPI:1649085291
Name:KONG, RACHEL MASUMI (PT, DPT)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MASUMI
Last Name:KONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E OAK ST UNIT 308
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5178
Mailing Address - Country:US
Mailing Address - Phone:510-780-6395
Mailing Address - Fax:
Practice Address - Street 1:520 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5229
Practice Address - Country:US
Practice Address - Phone:863-583-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist