Healthcare Provider Details

I. General information

NPI: 1043940505
Provider Name (Legal Business Name): TIONG YEE TAN LICENSED CLINICAL SOCIAL WORKER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 10/29/2023
Certification Date: 10/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BIRCH STREET WEST TOWER SUITE 3000 ATTENTION: MONTES LCSW
NEWPORT BEACH CA
92660-2140
US

IV. Provider business mailing address

5000 BIRCH STREET WEST TOWER SUITE 3000 ATTENTION: MONTES LCSW
NEWPORT BEACH CA
92660-2140
US

V. Phone/Fax

Practice location:
  • Phone: 949-229-6943
  • Fax: 949-576-3913
Mailing address:
  • Phone: 949-229-6943
  • Fax: 949-576-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TIONG YEE TAN
Title or Position: DIRECTOR
Credential: LCSW
Phone: 949-229-6943