Healthcare Provider Details

I. General information

NPI: 1104411784
Provider Name (Legal Business Name): MICHELLE WONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 S ALAMEDA ST FL 2
LOS ANGELES CA
90021-1656
US

IV. Provider business mailing address

14377 TELLURIDE DR
BALDWIN PARK CA
91706-5421
US

V. Phone/Fax

Practice location:
  • Phone: 213-289-3578
  • Fax: 213-357-3667
Mailing address:
  • Phone: 626-384-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number124666
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number124666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: