Basic Information
| Provider Information | |||||||||
| NPI: | 1659962405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | TONY | ||||||||
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| Credential: | LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14435 CAMERON CT | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530051600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142008656 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16535 W BLUEMOUND RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530055906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
| FaxNumber: | 2628216180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2021 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 7045 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.