Provider Demographics
NPI:1861131088
Name:WONG, KENNEDY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNEDY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 CARPENTER ST UNIT 1F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3910
Mailing Address - Country:US
Mailing Address - Phone:302-463-1978
Mailing Address - Fax:
Practice Address - Street 1:22 N PENNELL RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5520
Practice Address - Country:US
Practice Address - Phone:267-551-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-04
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019805103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical