Provider Demographics
NPI:1578859799
Name:WONG, ELIZABETH (MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 S BASCOM AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3509
Mailing Address - Country:US
Mailing Address - Phone:408-885-9000
Mailing Address - Fax:408-885-9009
Practice Address - Street 1:1150 S BASCOM AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3509
Practice Address - Country:US
Practice Address - Phone:408-885-9000
Practice Address - Fax:408-885-9009
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11388225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics