Provider Demographics
NPI:1871142463
Name:WONG, MIAOSUE S
Entity type:Individual
Prefix:
First Name:MIAOSUE
Middle Name:S
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10715 TRIPP CT
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5378
Mailing Address - Country:US
Mailing Address - Phone:216-659-1812
Mailing Address - Fax:
Practice Address - Street 1:8870 S DUFFY AVE
Practice Address - Street 2:
Practice Address - City:HOMETOWN
Practice Address - State:IL
Practice Address - Zip Code:60456-1140
Practice Address - Country:US
Practice Address - Phone:708-423-7360
Practice Address - Fax:708-499-7679
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009171225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist