Provider Demographics
NPI:1609432277
Name:WONG, MECLENA ABIGAIL (PTA)
Entity Type:Individual
Prefix:
First Name:MECLENA ABIGAIL
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 S ELISEO DR
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2006
Practice Address - Country:US
Practice Address - Phone:415-461-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09740225200000X
CA50540225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant