Provider Demographics
NPI:1598031254
Name:WONG, ALICE (MT-BC)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 FRONTERA WAY
Mailing Address - Street 2:#312
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-2801
Mailing Address - Country:US
Mailing Address - Phone:415-710-3887
Mailing Address - Fax:
Practice Address - Street 1:1550 FRONTERA WAY
Practice Address - Street 2:#312
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-2801
Practice Address - Country:US
Practice Address - Phone:415-710-3887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA046444174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist