Healthcare Provider Details

I. General information

NPI: 1174330740
Provider Name (Legal Business Name): KELLY VUONG ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N BARRANCA ST
WEST COVINA CA
91791-1637
US

IV. Provider business mailing address

100 N BARRANCA ST
WEST COVINA CA
91791-1637
US

V. Phone/Fax

Practice location:
  • Phone: 626-433-1311
  • Fax:
Mailing address:
  • Phone: 626-433-1311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW122923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: