Provider Demographics
NPI:1285942334
Name:WANG, MARTHA JUI-LAN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:JUI-LAN
Last Name:WANG
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 1:1230 NE 3RD ST STE A-160D
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4367
Mailing Address - Country:US
Mailing Address - Phone:818-253-9264
Mailing Address - Fax:
Practice Address - Street 1:1230 NE 3RD ST STE A-160D
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4367
Practice Address - Country:US
Practice Address - Phone:818-253-9264
Practice Address - Fax:844-204-5067
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2518103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500681394Medicaid