Provider Demographics
NPI:1700313517
Name:WONG, ANNE RENE
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:RENE
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MA AYE MYA
Other - Middle Name:
Other - Last Name:MON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2671 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:982 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2911
Practice Address - Country:US
Practice Address - Phone:415-597-8043
Practice Address - Fax:415-597-8004
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA107709106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program