Basic Information
| Provider Information | |||||||||
| NPI: | 1669144721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONGE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC-CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7240 E SOUTHGATE DR STE G | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163914293 | ||||||||
| FaxNumber: | 9163914247 | ||||||||
| Practice Location | |||||||||
| Address1: | 7240 E SOUTHGATE DR STE G | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163914293 | ||||||||
| FaxNumber: | 9163914247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C28341214 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.