Provider Demographics
NPI:1528521820
Name:HARRISON-WONG, SOPHIA LIN
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:LIN
Last Name:HARRISON-WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:LIN
Other - Last Name:HARRISON-WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:350 FAIRWAY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1834
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:1811 GRAND CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8107
Practice Address - Country:US
Practice Address - Phone:774-182-9788
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 390200000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician