Provider Demographics
NPI:1851757009
Name:WONG, CONNIE MABEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MABEL
Last Name:WONG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E DEL MAR BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2552
Mailing Address - Country:US
Mailing Address - Phone:626-564-2700
Mailing Address - Fax:626-564-2770
Practice Address - Street 1:200 E DEL MAR BLVD STE 112
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2552
Practice Address - Country:US
Practice Address - Phone:626-564-2700
Practice Address - Fax:626-564-2770
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15837225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist