Provider Demographics
NPI:1679081699
Name:WONG, MIKI MICHELLE
Entity type:Individual
Prefix:
First Name:MIKI
Middle Name:MICHELLE
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 1:5762 BOLSA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-1172
Mailing Address - Country:US
Mailing Address - Phone:714-292-2322
Mailing Address - Fax:714-866-4153
Practice Address - Street 1:151 KALMUS DR STE L1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5978
Practice Address - Country:US
Practice Address - Phone:714-292-2322
Practice Address - Fax:714-866-4153
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-31103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst