MEDICARE: VIVIAN THAO NGUYEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	11936391	CO

General Provider Information

NPI Number	:	1306494984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN THAO NGUYEN

Provider Business Mailing Address
First Line	:	8810 HEWITT PL APT 28
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92844-2681
Country	:	US
Telephone Number	:	310-279-6777
Fax Number	:

Provider Business Practice Location Address
First Line	:	12062 VALLEY VIEW ST STE 103
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92845-1738
Country	:	US
Telephone Number	:	756-444-9002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2019
Last Update Date	:	08/28/2019

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