=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255782835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN LAM NGUYEN LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2016
-----------------------------------------------------
Last Update Date | 02/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1321 NORTH CAROLAN AVE
-----------------------------------------------------
City | BIRLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-763-8072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 BOVET RD # 242
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94402-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-763-8072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 93375
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------