Provider Demographics
NPI:1649480039
Name:WONGSONEGORO, AMANDA C (CMT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:C
Last Name:WONGSONEGORO
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 KEOKUK ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2729
Mailing Address - Country:US
Mailing Address - Phone:707-762-4316
Mailing Address - Fax:707-762-4316
Practice Address - Street 1:35 PETALUMA BLVD N
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3001
Practice Address - Country:US
Practice Address - Phone:707-477-5402
Practice Address - Fax:707-762-4316
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist