Healthcare Provider Details

I. General information

NPI: 1053825505
Provider Name (Legal Business Name): MOUNTAIN THERAPY COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 EMERALD BAY RD STE 303
SOUTH LAKE TAHOE CA
96150-9400
US

IV. Provider business mailing address

870 EMERALD BAY RD STE 303
SOUTH LAKE TAHOE CA
96150-9400
US

V. Phone/Fax

Practice location:
  • Phone: 415-806-0275
  • Fax: 530-600-0063
Mailing address:
  • Phone: 415-806-0275
  • Fax: 530-600-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW WONG
Title or Position: OWNER
Credential: M.A., PSY.D.
Phone: 415-806-0275