Provider Demographics
NPI:1922177484
Name:WONG, KATHLEEN LUCILE (PT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:LUCILE
Last Name:WONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 W VERNAL WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-1622
Mailing Address - Country:US
Mailing Address - Phone:209-368-7433
Mailing Address - Fax:209-368-4219
Practice Address - Street 1:631 S HAM LN
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3532
Practice Address - Country:US
Practice Address - Phone:209-368-7433
Practice Address - Fax:209-368-4219
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT270700Medicare ID - Type Unspecified
CAP65467Medicare UPIN