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General NPI Number Information
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NPI Number | 1114354529
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Entity Type | Individual
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Provider Name | REBECCA L WONG PH.D.
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Gender | Female
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Dates
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Enumeration Date | 09/30/2013
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Last Update Date | 09/30/2013
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Provider Practice Location Address
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Address Line | 703 3RD ST ROOM 1120
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City | WEST LAFAYETTE
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State | IN
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Zip | 47907-2081
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Country | US
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Telephone | 765-494-6995
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Fax | 765-496-3004
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Provider Business Mailing Address
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Address Line | 703 3RD ST ROOM 1120
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City | WEST LAFAYETTE
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State | IN
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Zip | 47907-2081
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Country | US
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Telephone | 765-494-6995
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Fax | 765-496-3004
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20040228A
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License Number State | IN
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