Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003147562 |
---|---|
Provider Name | Michael Gong |
First Address | Watsonville, CA 95076-4826 |
Second Address | Watsonville, CA 95076-4826 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2010 |
Last Update Date | 22/01/2010 |