Provider Demographics
NPI:1114354529
Name:WONG, REBECCA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:WONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 3RD ST
Mailing Address - Street 2:ROOM 1120
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2081
Mailing Address - Country:US
Mailing Address - Phone:765-494-6995
Mailing Address - Fax:765-496-3004
Practice Address - Street 1:703 3RD ST
Practice Address - Street 2:ROOM 1120
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2081
Practice Address - Country:US
Practice Address - Phone:765-494-6995
Practice Address - Fax:765-496-3004
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040228A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist