MEDICARE: KOY T PHAN 101YM0800X

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1952456121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOY T PHAN 101YM0800X

Provider Business Mailing Address
First Line	:	3905 MACDONALD AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94805-2229
Country	:	US
Telephone Number	:	510-233-7555
Fax Number	:	510-233-4545

Provider Business Practice Location Address
First Line	:	3905 MACDONALD AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94805-2229
Country	:	US
Telephone Number	:	510-233-7555
Fax Number	:	510-233-4545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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