Healthcare Provider Details

I. General information

NPI: 1689024432
Provider Name (Legal Business Name): ELIZABETH WONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 DIVISION ST STE 101
OREGON CITY OR
97045-1589
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-722-3705
  • Fax:
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL8132
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: