MEDICARE: EMMA CATHERINE WONG PT, DPT

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	225100000X	Physical Therapist	300560	CA

General Provider Information

NPI Number	:	1770258519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA CATHERINE WONG PT, DPT

Provider Business Mailing Address
First Line	:	2635 CANTERBURY RD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-1530
Country	:	US
Telephone Number	:	626-788-7960
Fax Number	:

Provider Business Practice Location Address
First Line	:	17071 VENTURA BLVD STE 103
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-4142
Country	:	US
Telephone Number	:	818-232-4884
Fax Number	:

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

Provider Enumeration Date	:	08/13/2021
Last Update Date	:	08/13/2021

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