=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215964853
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE WONG PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 04/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1842 BEACON ST STE 402
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02445-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-283-9739
-----------------------------------------------------
Fax | 888-972-6581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68 SEAVERNS AVE APT A
-----------------------------------------------------
City | JAMAICA PLAIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-283-9739
-----------------------------------------------------
Fax | 857-972-6581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 8414
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 8414
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------