Healthcare Provider Details

I. General information

NPI: 1043408024
Provider Name (Legal Business Name): CHRISTINE WUNG PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 12TH ST SE WVP BOULDER CREEK
SALEM OR
97302
US

IV. Provider business mailing address

PO BOX 4025
SALEM OR
97302-1025
US

V. Phone/Fax

Practice location:
  • Phone: 503-967-1411
  • Fax:
Mailing address:
  • Phone: 503-269-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1923
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: