Provider Demographics
NPI:1538837992
Name:WONG, CRYSTAL (M ED)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 N 63RD ST APT B3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-2657
Mailing Address - Country:US
Mailing Address - Phone:714-376-2550
Mailing Address - Fax:
Practice Address - Street 1:225 E CITY AVE STE 15
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1724
Practice Address - Country:US
Practice Address - Phone:856-346-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005474103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst