MEDICARE: KELLI MICHIKO WONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OT-141	HI

General Provider Information

NPI Number	:	1548538176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI MICHIKO WONG

Provider Business Mailing Address
First Line	:	99-080 KAUHALE ST STE D9
Second Line	:
City	:	AIEA
State	:	HI
Zip	:	96701-4114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	99-080 KAUHALE ST STE D9
Second Line	:
City	:	AIEA
State	:	HI
Zip	:	96701-4114
Country	:	US
Telephone Number	:	808-483-4918
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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Directions to “ KELLI MICHIKO WONG ” Practice Location

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