Provider Demographics
NPI:1487382339
Name:WONG, MICHELLE GLORIA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GLORIA
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8534 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3312
Mailing Address - Country:US
Mailing Address - Phone:224-817-1956
Mailing Address - Fax:
Practice Address - Street 1:715 LAKE ST STE 806
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1417
Practice Address - Country:US
Practice Address - Phone:773-312-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist