Basic Information
| Provider Information | |||||||||
| NPI: | 1770615551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WING | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | DEGUISA | ||||||||
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| Credential: | MA, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1840 GRIFFITH PARK BLVD APT 2 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900261046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238190609 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2620 INDUSTRY WAY | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106318004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC #47514 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 106H00000X | 01 | CA | MENTAL HEALTH | OTHER |