Provider Demographics
NPI:1912796020
Name:FONG, ANDREW JAY
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAY
Last Name:FONG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31477 MANGO FADE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:FL
Mailing Address - Zip Code:33576-4692
Mailing Address - Country:US
Mailing Address - Phone:404-781-4652
Mailing Address - Fax:
Practice Address - Street 1:6421 N FLORIDA AVE STE D-1458
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6007
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty