Provider Demographics
NPI:1144801929
Name:WONG, NIA (MS LMFT)
Entity Type:Individual
Prefix:
First Name:NIA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16767 BERNARDO CENTER DR # 270511
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2509
Mailing Address - Country:US
Mailing Address - Phone:650-394-6248
Mailing Address - Fax:
Practice Address - Street 1:11202 MONTICOOK CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-3124
Practice Address - Country:US
Practice Address - Phone:650-394-6248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT41037106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist