Healthcare Provider Details

I. General information

NPI: 1649621467
Provider Name (Legal Business Name): PHAL TITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHAL VAY

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 E PACIFIC COAST HWY STE 600
LONG BEACH CA
90804-6914
US

IV. Provider business mailing address

4510 E PACIFIC COAST HWY STE 600
LONG BEACH CA
90804-6914
US

V. Phone/Fax

Practice location:
  • Phone: 562-346-1100
  • Fax: 562-961-7604
Mailing address:
  • Phone: 562-346-1100
  • Fax: 562-961-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: