Healthcare Provider Details

I. General information

NPI: 1952825598
Provider Name (Legal Business Name): IRENE PHUONG BAO VAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 PATRICK HENRY DR
SANTA CLARA CA
95054-1819
US

IV. Provider business mailing address

2010 EL CAMINO REAL # 1392
SANTA CLARA CA
95050-4051
US

V. Phone/Fax

Practice location:
  • Phone: 408-214-9736
  • Fax:
Mailing address:
  • Phone: 408-284-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number127828
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: