Healthcare Provider Details

I. General information

NPI: 1790107597
Provider Name (Legal Business Name): PETERSON Q PHAM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 ELM AVE STE 302
LONG BEACH CA
90813-3295
US

IV. Provider business mailing address

PO BOX 1789
GARDEN GROVE CA
92842-1789
US

V. Phone/Fax

Practice location:
  • Phone: 562-247-7740
  • Fax:
Mailing address:
  • Phone: 657-206-0035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: