Healthcare Provider Details

I. General information

NPI: 1306299326
Provider Name (Legal Business Name): HIEN-THAO PHAN LICSW, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 S OTHELLO ST
SEATTLE WA
98118-3510
US

IV. Provider business mailing address

PO BOX 3007
SEATTLE WA
98114-3007
US

V. Phone/Fax

Practice location:
  • Phone: 206-788-3500
  • Fax:
Mailing address:
  • Phone: 206-788-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSC60726290
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCG60183725
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC60726290
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW61296741
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: