Provider Demographics
NPI:1932248028
Name:NG, GWENDOLYN B (CTRS)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:B
Last Name:NG
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 N DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2127
Mailing Address - Country:US
Mailing Address - Phone:626-433-1311
Mailing Address - Fax:626-433-1313
Practice Address - Street 1:9864 BALDWIN PL
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2202
Practice Address - Country:US
Practice Address - Phone:626-433-1311
Practice Address - Fax:626-433-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225800000X
CA33241225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist