Provider Demographics
NPI:1518471069
Name:WONG, LYNSEY
Entity Type:Individual
Prefix:
First Name:LYNSEY
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 1:4410 N SACRAMENTO AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3860
Mailing Address - Country:US
Mailing Address - Phone:312-402-4415
Mailing Address - Fax:
Practice Address - Street 1:4410 N SACRAMENTO AVE APT 3E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3860
Practice Address - Country:US
Practice Address - Phone:312-402-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1910254103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool