Healthcare Provider Details

I. General information

NPI: 1699412171
Provider Name (Legal Business Name): PRISCILLA PHAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D.L. INGRAM AVE BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

27 SOMDG 104 W. D.L. INGRAM AVE
CANNON AFB NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-1108
  • Fax:
Mailing address:
  • Phone: 575-784-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008963
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: