MEDICARE: MS. MARCIA LOUISE WONG C.A.S.

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	103TS0200X	School Psychologist	755262	IN

General Provider Information

NPI Number	:	1871768580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARCIA LOUISE WONG C.A.S.

Provider Business Mailing Address
First Line	:	52845 SWANSON DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1274
Country	:	US
Telephone Number	:	574-272-4880
Fax Number	:

Provider Business Practice Location Address
First Line	:	52845 SWANSON DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1274
Country	:	US
Telephone Number	:	574-272-4880
Fax Number	:

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

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	04/23/2008

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