Organization
MOUNTAIN THERAPY COLLABORATIVE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MATTHEW WONG M.A., PSY.D. (OWNER)
(415) 806-0275
Entity
Organization
Contact information
Practice address
870 EMERALD BAY RD STE 303, SOUTH LAKE TAHOE, CA 96150-9400
(415) 806-0275
(530) 600-0063
Mailing address
870 EMERALD BAY RD STE 303, SOUTH LAKE TAHOE, CA 96150-9400
(415) 806-0275
(530) 600-0063
Taxonomy
Speciality
Code
Description
License number
State
103TP2701X
Group Psychotherapy Psychologist
Primary
—
—
1041C0700X
Clinical Social Worker
—
—
224Z00000X
Occupational Therapy Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1598157117
—
CA
05
—
1619169653
—
NC
Enumeration date
11/20/2017
Last updated
11/20/2017
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