Provider Demographics
NPI:1215964853
Name:WONG, BONNIE (PHD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 SEAVERNS AVE APT A
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3098
Mailing Address - Country:US
Mailing Address - Phone:617-283-9739
Mailing Address - Fax:857-972-6581
Practice Address - Street 1:1842 BEACON ST STE 402
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-1922
Practice Address - Country:US
Practice Address - Phone:617-283-9739
Practice Address - Fax:888-972-6581
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8414103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0599077Medicaid
MAQ53407Medicare UPIN
MA0599077Medicaid