Provider Demographics
NPI:1487320214
Name:WONG, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 OCEAN PARK BLVD APT 5
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4941
Mailing Address - Country:US
Mailing Address - Phone:520-979-1497
Mailing Address - Fax:
Practice Address - Street 1:2271 ALPINE BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1101
Practice Address - Country:US
Practice Address - Phone:520-979-1497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20151101YP2500X
CA16962101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional