Provider Demographics
NPI:1104411784
Name:WONG, MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14377 TELLURIDE DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5421
Mailing Address - Country:US
Mailing Address - Phone:626-384-7855
Mailing Address - Fax:
Practice Address - Street 1:777 S ALAMEDA ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90021-1656
Practice Address - Country:US
Practice Address - Phone:213-289-3578
Practice Address - Fax:213-357-3667
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1246661041C0700X, 101YM0800X
CA99676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical