Provider Demographics
NPI:1255810370
Name:WONG, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LEUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1090 S CENTRAL PKWY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-1353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 S CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOUSE
Practice Address - State:CA
Practice Address - Zip Code:95391-1353
Practice Address - Country:US
Practice Address - Phone:209-836-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool