Provider Demographics
NPI:1194609966
Name:GONG, MARLEN
Entity type:Individual
Prefix:MRS
First Name:MARLEN
Middle Name:
Last Name:GONG
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 1:1877 E SAN GREGORIO CT
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-6972
Mailing Address - Country:US
Mailing Address - Phone:559-361-5644
Mailing Address - Fax:
Practice Address - Street 1:500 S LASPINA ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-5929
Practice Address - Country:US
Practice Address - Phone:559-556-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230120791103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool