Healthcare Provider Details

I. General information

NPI: 1124466248
Provider Name (Legal Business Name): QUE PHAN VUONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ALAMEDA DE LAS PULGAS
SAN MATEO CA
94403-1222
US

IV. Provider business mailing address

1950 ALAMEDA DE LAS PULGAS
SAN MATEO CA
94403-1222
US

V. Phone/Fax

Practice location:
  • Phone: 650-454-4711
  • Fax:
Mailing address:
  • Phone: 650-454-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberASW75320
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW75320
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW75320
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW99848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: