Healthcare Provider Details

I. General information

NPI: 1578896429
Provider Name (Legal Business Name): NHUNG PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N BEGONIA AVE STE 1009
ONTARIO CA
91762-2104
US

IV. Provider business mailing address

1011 N BEGONIA AVE STE 1009
ONTARIO CA
91762-2104
US

V. Phone/Fax

Practice location:
  • Phone: 800-683-2945
  • Fax:
Mailing address:
  • Phone: 800-683-2945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY28271
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY28271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: