Provider Demographics
NPI:1932945821
Name:WONG, AUDREY MCKENNA (OTR/L)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:MCKENNA
Last Name:WONG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 LAVER CT
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-6767
Mailing Address - Country:US
Mailing Address - Phone:650-823-9714
Mailing Address - Fax:
Practice Address - Street 1:797 E FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2805
Practice Address - Country:US
Practice Address - Phone:408-738-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist