Basic Information
| Provider Information | |||||||||
| NPI: | 1861768723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., BCBA-D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 800 FERRARI STE 100 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917645031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | 9092044149 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 FERRARI STE 100 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917645031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | 9092044149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-12-10019 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.