=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306331046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINA WONG, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2018
-----------------------------------------------------
Last Update Date | 06/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42 NEWPORT PL
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06825-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-671-5836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 NEWPORT PL
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06825-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-671-5836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRINA WONG
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 203-671-5836
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 001955
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------