Provider Demographics
NPI:1871768580
Name:WONG, MARCIA LOUISE (CAS)
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:LOUISE
Last Name:WONG
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52845 SWANSON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1274
Mailing Address - Country:US
Mailing Address - Phone:574-272-4880
Mailing Address - Fax:
Practice Address - Street 1:52845 SWANSON DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1274
Practice Address - Country:US
Practice Address - Phone:574-272-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN755262103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool