Provider Demographics
NPI:1336550052
Name:WONG, CARMEN K
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:K
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:K
Other - Last Name:CHAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6344 SAUNDERS ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2041
Mailing Address - Country:US
Mailing Address - Phone:973-819-6888
Mailing Address - Fax:
Practice Address - Street 1:8114 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3789
Practice Address - Country:US
Practice Address - Phone:718-899-9810
Practice Address - Fax:718-899-9699
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJC32561117258832390200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program