Healthcare Provider Details

I. General information

NPI: 1720574304
Provider Name (Legal Business Name): LOAN PHAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 MONTGOMERY PKWY NE STE 1-K
ALBUQUERQUE NM
87111-3876
US

IV. Provider business mailing address

10401 MONTGOMERY PKWY NE STE 1-K
ALBUQUERQUE NM
87111-3876
US

V. Phone/Fax

Practice location:
  • Phone: 505-227-7623
  • Fax:
Mailing address:
  • Phone: 505-227-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0063831
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: