Provider Demographics
NPI:1720367956
Name:WONG, ALBERT (PHD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 H STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-545-8899
Mailing Address - Fax:415-545-8899
Practice Address - Street 1:1 H STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-545-8899
Practice Address - Fax:415-545-8899
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27690103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical