Provider Demographics
NPI:1750676680
Name:WONG, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22215 NORTHERN BLVD
Mailing Address - Street 2:SUITE LLC
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3603
Mailing Address - Country:US
Mailing Address - Phone:718-225-7500
Mailing Address - Fax:718-225-7555
Practice Address - Street 1:22215 NORTHERN BLVD
Practice Address - Street 2:SUITE LLC
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3603
Practice Address - Country:US
Practice Address - Phone:718-225-7500
Practice Address - Fax:718-225-7555
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013282225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist