MEDICARE: NIA WONG M.S. LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT41037	CA

General Provider Information

NPI Number	:	1144801929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIA WONG M.S. LMFT

Provider Business Mailing Address
First Line	:	16767 BERNARDO CENTER DR # 270511
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-2509
Country	:	US
Telephone Number	:	650-394-6248
Fax Number	:

Provider Business Practice Location Address
First Line	:	11202 MONTICOOK CT
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-3124
Country	:	US
Telephone Number	:	650-394-6248
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	05/11/2021

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