Provider Demographics
NPI:1861768723
Name:WONG, CONNIE LYNN (PHD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:LYNN
Last Name:WONG
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 FERRARI STE 100
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5031
Mailing Address - Country:US
Mailing Address - Phone:909-484-2848
Mailing Address - Fax:909-204-4149
Practice Address - Street 1:800 FERRARI STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5031
Practice Address - Country:US
Practice Address - Phone:909-484-2848
Practice Address - Fax:909-204-4149
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-12-10019103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst