Provider Demographics
NPI:1558812123
Name:WONG, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UW AUTISM CTR
Mailing Address - Street 2:BOX 357921 CHDD CD-205
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7921
Mailing Address - Country:US
Mailing Address - Phone:510-589-5875
Mailing Address - Fax:206-598-7815
Practice Address - Street 1:UW AUTISM CTR
Practice Address - Street 2:1701 NE COLUMBIA RD
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7921
Practice Address - Country:US
Practice Address - Phone:206-616-8642
Practice Address - Fax:206-598-7815
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician