Provider Demographics
NPI:1215098595
Name:WONG, RICHIE PHU (PSYD)
Entity type:Individual
Prefix:
First Name:RICHIE
Middle Name:PHU
Last Name:WONG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19231 VICTORY BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6321
Mailing Address - Country:US
Mailing Address - Phone:818-708-4500
Mailing Address - Fax:
Practice Address - Street 1:19231 VICTORY BLVD STE 110
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6321
Practice Address - Country:US
Practice Address - Phone:818-708-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CAPSY23687103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program