Provider Demographics
NPI:1215471412
Name:WONG, MABEL
Entity type:Individual
Prefix:
First Name:MABEL
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 1:114 WOODCREST LN
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2150
Mailing Address - Country:US
Mailing Address - Phone:240-543-0845
Mailing Address - Fax:
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA
Practice Address - Street 2:SUITE 165
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3636
Practice Address - Country:US
Practice Address - Phone:949-951-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist