Provider Demographics
NPI:1073824397
Name:WONG, JUSTIN CHING LAM
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CHING LAM
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 FREMONT AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3224
Mailing Address - Country:US
Mailing Address - Phone:626-634-2203
Mailing Address - Fax:
Practice Address - Street 1:3280 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3103
Practice Address - Country:US
Practice Address - Phone:626-634-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA89992106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7667OtherMEDI-CAL
CA95-2633765OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7708OtherMEDI-CAL