Provider Demographics
NPI:1063998144
Name:WONG, CAROLYN LEE (MS, LMFT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LEE
Last Name:WONG
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:SUE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 W SIERRA MADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024
Mailing Address - Country:US
Mailing Address - Phone:626-325-9316
Mailing Address - Fax:626-921-0005
Practice Address - Street 1:1447 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4154
Practice Address - Country:US
Practice Address - Phone:626-325-9316
Practice Address - Fax:626-921-0005
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96959106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist