Provider Demographics
NPI:1285708024
Name:WONG, MIMI (PHD)
Entity type:Individual
Prefix:
First Name:MIMI
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:PO BOX 5330
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94083-5330
Mailing Address - Country:US
Mailing Address - Phone:415-857-1157
Mailing Address - Fax:
Practice Address - Street 1:870 MARKET ST
Practice Address - Street 2:SUITE 744
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3099
Practice Address - Country:US
Practice Address - Phone:415-857-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25379103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist