Provider Demographics
NPI:1730202250
Name:WONG, WALLACE WAI CHEONG (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:WAI CHEONG
Last Name:WONG
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2948 LANING RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-6434
Mailing Address - Country:US
Mailing Address - Phone:619-265-5203
Mailing Address - Fax:
Practice Address - Street 1:2948 LANING RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6434
Practice Address - Country:US
Practice Address - Phone:619-265-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19920103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical