=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235409624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INGRID WILSON HUANG PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2012
-----------------------------------------------------
Last Update Date | 11/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 PARKER RD
-----------------------------------------------------
City | CANTONMENT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-699-4640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2220 PARKER RD
-----------------------------------------------------
City | CANTONMENT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32533-8177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-699-4640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1626
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------