Provider Demographics
NPI:1811465156
Name:WANG, NA (LAC)
Entity type:Individual
Prefix:MISS
First Name:NA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BROADWAY STE 336
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-1549
Mailing Address - Country:US
Mailing Address - Phone:626-215-3602
Mailing Address - Fax:212-361-0019
Practice Address - Street 1:6445 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-2337
Practice Address - Country:US
Practice Address - Phone:626-215-3602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006157171100000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional