Provider Demographics
NPI:1215701602
Name:WONG, MARIA (OTR/L)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14500 FRUITVALE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-6165
Practice Address - Country:US
Practice Address - Phone:408-741-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25558225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist