Provider Demographics
NPI:1386848992
Name:WONG, LISA W (MSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:W
Last Name:WONG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 BANCROFT AVE STE 125 A
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2415
Mailing Address - Country:US
Mailing Address - Phone:510-777-3800
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE STE 125 A
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2415
Practice Address - Country:US
Practice Address - Phone:510-777-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11474104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker