Provider Demographics
NPI:1154602621
Name:WONG, MICHAEL DENNIS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DENNIS
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 STEDMAN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-6009
Mailing Address - Country:US
Mailing Address - Phone:617-734-4720
Mailing Address - Fax:
Practice Address - Street 1:35 MEMORIAL RD
Practice Address - Street 2:12A
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1702
Practice Address - Country:US
Practice Address - Phone:617-623-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling