Provider Demographics
NPI:1013230929
Name:WONG, TAT
Entity Type:Individual
Prefix:
First Name:TAT
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SINCERE
Other - Middle Name:
Other - Last Name:JUSTICE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12353 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8305
Mailing Address - Country:US
Mailing Address - Phone:562-484-3385
Mailing Address - Fax:
Practice Address - Street 1:12353 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-8305
Practice Address - Country:US
Practice Address - Phone:562-484-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1512013461Medicaid
1512013461Medicare PIN
CA1512013461Medicare UPIN