MEDICARE: DR. EVAON CHUKLAN WONG-KIM PHD, MSW, MPH

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	1041C0700X	Clinical Social Worker	LCS 17244	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17244	OTHER	CA	LCSW

General Provider Information

NPI Number	:	1396117222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAON CHUKLAN WONG-KIM PHD, MSW, MPH

Provider Business Mailing Address
First Line	:	411 BALRA DR
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-3314
Country	:	US
Telephone Number	:	510-528-0635
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 BALRA DR
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-3314
Country	:	US
Telephone Number	:	510-528-0635
Fax Number	:

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

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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