Provider Demographics
NPI:1134677305
Name:WONG, NATASHA (PSYD)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 NE HIGHWAY 99W # 169
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2720
Mailing Address - Country:US
Mailing Address - Phone:503-560-9828
Mailing Address - Fax:503-215-8556
Practice Address - Street 1:1271 NE HIGHWAY 99W # 169
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2720
Practice Address - Country:US
Practice Address - Phone:503-560-9828
Practice Address - Fax:503-215-8556
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical