Provider Demographics
NPI:1487991188
Name:WONG, VANSEN (OTR/L)
Entity type:Individual
Prefix:
First Name:VANSEN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 AVOCET CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8134
Mailing Address - Country:US
Mailing Address - Phone:916-833-3017
Mailing Address - Fax:
Practice Address - Street 1:2317 AVOCET CT
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-8134
Practice Address - Country:US
Practice Address - Phone:916-833-3017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA14840225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor