Provider Demographics
NPI:1629080981
Name:WONG, DEBORAH A (PHD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:WONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-4531
Mailing Address - Country:US
Mailing Address - Phone:937-335-7876
Mailing Address - Fax:
Practice Address - Street 1:6465 REFLECTIONS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2355
Practice Address - Country:US
Practice Address - Phone:614-792-1108
Practice Address - Fax:614-792-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3838103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0648599Medicaid
OHQ43207Medicare UPIN
OH0648599Medicaid