Healthcare Provider Details

I. General information

NPI: 1689582124
Provider Name (Legal Business Name): FUEY CLARIE PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 VALLECITO ST
SHASTA LAKE CA
96019-9348
US

IV. Provider business mailing address

4411 MOUNTAIN LAKES BLVD
REDDING CA
96003-1446
US

V. Phone/Fax

Practice location:
  • Phone: 530-275-7020
  • Fax: 530-275-7025
Mailing address:
  • Phone: 530-245-7900
  • Fax: 530-245-7920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19916
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: