Basic Information
| Provider Information | |||||||||
| NPI: | 1760098032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHUNG | ||||||||
| FirstName: | TAI | ||||||||
| MiddleName: | THIEN | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9353 VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEMEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917701923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262872988 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9353 VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEMEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917701923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262872988 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 780978 | CA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363L00000X | NP95019571 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.