Healthcare Provider Details

I. General information

NPI: 1326985698
Provider Name (Legal Business Name): MRS. VALERIE PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHASTA PHAN

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 DUTTON AVE
SANTA ROSA CA
95407-7891
US

IV. Provider business mailing address

2009 RAVELLO WAY
SANTA ROSA CA
95403-7256
US

V. Phone/Fax

Practice location:
  • Phone: 707-522-3322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: