Provider Demographics
NPI:1033343017
Name:WONG, MATTHEW (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 EMERALD BAY RD # 303
Mailing Address - Street 2:BOX #3
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-9403
Mailing Address - Country:US
Mailing Address - Phone:415-806-0275
Mailing Address - Fax:
Practice Address - Street 1:870 EMERALD BAY RD # 303
Practice Address - Street 2:BOX #3
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-9403
Practice Address - Country:US
Practice Address - Phone:415-806-0275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA26365103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program