Provider Demographics
NPI:1063057099
Name:PAEZ-WONG, BLAIR KAYNE (AMFT)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:KAYNE
Last Name:PAEZ-WONG
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:BLAIR
Other - Middle Name:KAYNE
Other - Last Name:PAEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMFT
Mailing Address - Street 1:1420 S MILLIKEN AVE STE 508
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-2337
Mailing Address - Country:US
Mailing Address - Phone:909-983-2020
Mailing Address - Fax:
Practice Address - Street 1:1420 S MILLIKEN AVE STE 508
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2337
Practice Address - Country:US
Practice Address - Phone:909-983-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist