Provider Demographics
NPI:1124476791
Name:WONG, ROSALINDA
Entity type:Individual
Prefix:
First Name:ROSALINDA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 ENSIGN PEAK CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-3482
Mailing Address - Country:US
Mailing Address - Phone:678-490-1694
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3390
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist