Provider Demographics
NPI:1396117222
Name:WONG-KIM, EVAON CHUKLAN (PHD, MSW, MPH)
Entity type:Individual
Prefix:DR
First Name:EVAON
Middle Name:CHUKLAN
Last Name:WONG-KIM
Suffix:
Gender:F
Credentials:PHD, MSW, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 BALRA DR
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3314
Mailing Address - Country:US
Mailing Address - Phone:510-528-0635
Mailing Address - Fax:
Practice Address - Street 1:411 BALRA DR
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3314
Practice Address - Country:US
Practice Address - Phone:510-528-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 172441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17244OtherLCSW