Provider Demographics
NPI:1811071194
Name:IM-WANG, SUNNY Y (MA)
Entity type:Individual
Prefix:
First Name:SUNNY
Middle Name:Y
Last Name:IM-WANG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 MITCHELL BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2068
Mailing Address - Country:US
Mailing Address - Phone:415-499-6828
Mailing Address - Fax:415-499-3080
Practice Address - Street 1:161 MITCHELL BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2068
Practice Address - Country:US
Practice Address - Phone:415-499-6828
Practice Address - Fax:415-499-3080
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist