Provider Demographics
NPI:1497403323
Name:WONG, STEPHANIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 S TIPPECANOE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2920
Mailing Address - Country:US
Mailing Address - Phone:909-703-3509
Mailing Address - Fax:
Practice Address - Street 1:1499 S TIPPECANOE AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2920
Practice Address - Country:US
Practice Address - Phone:909-703-3509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
CA32842235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist