Basic Information
| Provider Information | |||||||||
| NPI: | 1528453164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | THENG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KHOU | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | THENG | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13177 RAMONA BLVD | ||||||||
| Address2: | |||||||||
| City: | IRWINDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917063855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13177 RAMONA BLVD | ||||||||
| Address2: | |||||||||
| City: | IRWINDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917063855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263373828 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 2470A2800X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | Assistant Record Technician | 101YM0800X | ASW102637 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.