Provider Demographics
NPI:1780047381
Name:WONG, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E MAIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 E MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4149
Practice Address - Country:US
Practice Address - Phone:626-451-9903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist