Provider Demographics
NPI:1821597477
Name:WONG, SHERRY
Entity Type:Individual
Prefix:
First Name:SHERRY
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 1:162 WEST ST, BLDG 2, SUITE F
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416
Mailing Address - Country:US
Mailing Address - Phone:860-613-9930
Mailing Address - Fax:860-613-9952
Practice Address - Street 1:162 WEST ST, BLDG 2, SUITE F
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:860-613-9952
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
CT760103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist