Healthcare Provider Details

I. General information

NPI: 1770916413
Provider Name (Legal Business Name): PHUNG PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIE PHAN

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S EL CAMINO REAL
SAN MATEO CA
94403-2380
US

IV. Provider business mailing address

3009 WALL ST
SAN JOSE CA
95111-4601
US

V. Phone/Fax

Practice location:
  • Phone: 408-347-3120
  • Fax: 408-347-3121
Mailing address:
  • Phone: 650-578-8691
  • Fax: 650-393-8925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: