Healthcare Provider Details

I. General information

NPI: 1487382339
Provider Name (Legal Business Name): MICHELLE GLORIA WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 LAKE ST STE 806
OAK PARK IL
60301-1417
US

IV. Provider business mailing address

130 GEORGE ST APT 512
BENSENVILLE IL
60106-3181
US

V. Phone/Fax

Practice location:
  • Phone: 773-312-3612
  • Fax:
Mailing address:
  • Phone: 224-817-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.019984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: