Provider Demographics
NPI:1578270799
Name:WONG, VIVIAN (OTR/L)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 ELISSA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0058
Mailing Address - Country:US
Mailing Address - Phone:630-407-4157
Mailing Address - Fax:
Practice Address - Street 1:8282 WHITE OAK AVE STE 108&111
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7680
Practice Address - Country:US
Practice Address - Phone:909-586-0509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26537225X00000X
IL056.015187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist