Healthcare Provider Details

I. General information

NPI: 1437495900
Provider Name (Legal Business Name): ANTHONY VAN PHAN LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W METROPOLITAN DR # 120
ORANGE CA
92868-3504
US

IV. Provider business mailing address

4000 W METROPOLITAN DR # 120
ORANGE CA
92868-3504
US

V. Phone/Fax

Practice location:
  • Phone: 714-972-3700
  • Fax: 714-972-3744
Mailing address:
  • Phone: 714-972-3700
  • Fax: 714-972-3744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number113233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: