Provider Demographics
NPI:1790238426
Name:WONG, PETER (IMF93857)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:IMF93857
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1031
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-1031
Mailing Address - Country:US
Mailing Address - Phone:916-243-0568
Mailing Address - Fax:
Practice Address - Street 1:5150 SUNRISE BLVD STE H1
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4966
Practice Address - Country:US
Practice Address - Phone:916-243-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF93857106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist