Healthcare Provider Details

I. General information

NPI: 1255840575
Provider Name (Legal Business Name): VYVIAN PHAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 MONTGOMERY BLVD NE STE A
ALBUQUERQUE NM
87111-2468
US

IV. Provider business mailing address

1855 SMARTY JONES ST SE
ALBUQUERQUE NM
87123-2398
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-9080
  • Fax:
Mailing address:
  • Phone: 505-702-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0980
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115372
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: