Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 2017002012 | MO |
Y | 103TC0700X | Clinical Psychologist | 2017002012 | MO |
N | 103TC1900X | Counseling Psychologist | 2017002012 | MO |
NPI | 1073821096 |
---|---|
Provider Name | Dr. Wing Man Fong |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2010 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
490087956 | (05) | MO |