Provider Demographics
NPI:1073821096
Name:FONG, WING MAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:WING
Middle Name:MAN
Last Name:FONG
Suffix:
Gender:F
Credentials:PHD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8111
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-454-7759
Practice Address - Street 1:1 BARNES JEWISH HOSPITAL PLZ
Practice Address - Street 2:DIV NEUROLOGY NEUROPSYCHOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1003
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-454-7759
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2023-08-23
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Provider Licenses
StateLicense IDTaxonomies
MO2017002012103G00000X, 103TC1900X
IL071-010809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490087956Medicaid