Provider Demographics
NPI:1194377572
Name:WONG, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8795 FOLSOM BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3720
Mailing Address - Country:US
Mailing Address - Phone:916-448-2050
Mailing Address - Fax:916-448-6050
Practice Address - Street 1:8795 FOLSOM BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3720
Practice Address - Country:US
Practice Address - Phone:916-448-2050
Practice Address - Fax:916-448-6050
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician