Healthcare Provider Details

I. General information

NPI: 1639772429
Provider Name (Legal Business Name): KATHLEEN GAO PHOUA VANG M.S., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 E MINARETS AVE
FRESNO CA
93720-3010
US

IV. Provider business mailing address

7120 N MARKS AVE
FRESNO CA
93711-0268
US

V. Phone/Fax

Practice location:
  • Phone: 559-447-1114
  • Fax:
Mailing address:
  • Phone: 559-439-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122406
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number138881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: