=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275210387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHIE PHAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2023
-----------------------------------------------------
Last Update Date | 06/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1512 1ST AVE APT 301S
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 195-318-6173
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2346 MORMON TREK BLVD
-----------------------------------------------------
City | IOWA CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52246-4371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-519-9031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 119554
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------