Provider Demographics
NPI:1205972106
Name:WONG BAILEY, HEATHER (PSYD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WONG BAILEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:632 MASSACHUSETTS AVE
Mailing Address - Street 2:APARTMENT 316
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3327
Mailing Address - Country:US
Mailing Address - Phone:617-513-1004
Mailing Address - Fax:
Practice Address - Street 1:1 MIFFLIN PL
Practice Address - Street 2:SUITE 260
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4907
Practice Address - Country:US
Practice Address - Phone:617-513-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8260103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076761Medicaid
MAW 06347OtherBLUE CROSS BLUE SHIELD MA
9967078OtherAETNA
MAW51346Medicare ID - Type Unspecified