Healthcare Provider Details

I. General information

NPI: 1114231669
Provider Name (Legal Business Name): KELLY T PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 01/22/2023
Certification Date: 01/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 12TH ST STE 2
MODESTO CA
95354-0838
US

IV. Provider business mailing address

1015 12TH ST STE 2
MODESTO CA
95354-0838
US

V. Phone/Fax

Practice location:
  • Phone: 209-496-2327
  • Fax:
Mailing address:
  • Phone: 209-496-2327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY29070
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: