MEDICARE: DUSTIN KHANH PHAN LICSWA

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	SC61599639	WA

General Provider Information

NPI Number	:	1992517965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN KHANH PHAN LICSWA

Provider Business Mailing Address
First Line	:	5630 CALIFORNIA AVE SW APT 11
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-1534
Country	:	US
Telephone Number	:	706-633-0405
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 S OTHELLO ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-3562
Country	:	US
Telephone Number	:	706-633-0405
Fax Number	:

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

Provider Enumeration Date	:	01/24/2025
Last Update Date	:	01/24/2025

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