Provider Demographics
NPI:1730349184
Name:TONG, MAYRA LIZETH (CASEMANAGER)
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:LIZETH
Last Name:TONG
Suffix:
Gender:F
Credentials:CASEMANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 N PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6953
Mailing Address - Country:US
Mailing Address - Phone:209-476-8533
Mailing Address - Fax:
Practice Address - Street 1:4330 N PERSHING AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6953
Practice Address - Country:US
Practice Address - Phone:209-476-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3547419OtherDRIVER LICENSE