Provider Demographics
NPI:1992268601
Name:WANG, WALLY CHING-LI
Entity type:Individual
Prefix:
First Name:WALLY
Middle Name:CHING-LI
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16609 NE 50TH WAY
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-7021
Mailing Address - Country:US
Mailing Address - Phone:206-403-6005
Mailing Address - Fax:
Practice Address - Street 1:15600 REDMOND WAY STE 201
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3862
Practice Address - Country:US
Practice Address - Phone:206-321-4888
Practice Address - Fax:855-519-9505
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60933194101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health