Provider Demographics
NPI:1801473731
Name:WONG, STACEY (DPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17870 NEWHOPE ST STE 104-160
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5439
Mailing Address - Country:US
Mailing Address - Phone:714-429-0799
Mailing Address - Fax:
Practice Address - Street 1:1520 NUTMEG PL STE 111
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2557
Practice Address - Country:US
Practice Address - Phone:714-979-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist