Provider Demographics
NPI:1043588775
Name:WONG, TIMOTHY KENJI (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:KENJI
Last Name:WONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 OCEAN PARK BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3230
Mailing Address - Country:US
Mailing Address - Phone:310-845-6720
Mailing Address - Fax:
Practice Address - Street 1:3301 OCEAN PARK BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3230
Practice Address - Country:US
Practice Address - Phone:310-845-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28253103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB254589Medicare PIN