Provider Demographics
NPI:1629578182
Name:WONG, MAN WAI ALICE (DPT, CLT)
Entity type:Individual
Prefix:
First Name:MAN WAI
Middle Name:ALICE
Last Name:WONG
Suffix:
Gender:F
Credentials:DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43538 BANNOCKBURN DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2820
Mailing Address - Country:US
Mailing Address - Phone:248-787-8185
Mailing Address - Fax:
Practice Address - Street 1:15777 NORTHLINE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2300
Practice Address - Country:US
Practice Address - Phone:734-246-8125
Practice Address - Fax:734-246-8113
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist