Provider Demographics
NPI:1154730240
Name:FONG, LINDA ANANDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:ANANDA
Last Name:FONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7683
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-0683
Mailing Address - Country:US
Mailing Address - Phone:510-926-6812
Mailing Address - Fax:
Practice Address - Street 1:2519 MILVIA ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:510-926-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA867311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical