=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821792177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. LIANG-YAO WANG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2023
-----------------------------------------------------
Last Update Date | 06/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3164 21ST ST # 1095
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-224-2253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3164 21ST ST # 1095
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-224-2253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | TPPY2568
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY61043196
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 025691
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------