Basic Information
| Provider Information | |||||||||
| NPI: | 1699254623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONG | ||||||||
| FirstName: | KHANG | ||||||||
| MiddleName: | SY | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5129570156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
| FaxNumber: | 5129570156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2018 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 75157 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 75157 | 01 | TX | TEXAS STATE BOARD OF COUNSELORS | OTHER |