Healthcare Provider Details

I. General information

NPI: 1942477112
Provider Name (Legal Business Name): THIET VAN PHAN MHS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S GRAND AVE STE B
SANTA ANA CA
92705-4434
US

IV. Provider business mailing address

1300 S GRAND AVE STE B
SANTA ANA CA
92705-4434
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-6843
  • Fax: 714-834-6825
Mailing address:
  • Phone: 714-834-6843
  • Fax: 714-834-6825

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: