Healthcare Provider Details

I. General information

NPI: 1770247512
Provider Name (Legal Business Name): CHARISSA ANGELIQUE WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8811 S TACOMA WAY STE 204&206
LAKEWOOD WA
98499-4595
US

IV. Provider business mailing address

8811 S TACOMA WAY STE 204&206
LAKEWOOD WA
98499-4595
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-0320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB1167409
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: