Basic Information
| Provider Information | |||||||||
| NPI: | 1780175067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHUONG | ||||||||
| FirstName: | KYLAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | BEHAVIOR TECHNICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11037 WARNER AVE # 339 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027344292 | ||||||||
| FaxNumber: | 7145966274 | ||||||||
| Practice Location | |||||||||
| Address1: | 11037 WARNER AVE # 339 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027344292 | ||||||||
| FaxNumber: | 8882933374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2018 | ||||||||
| LastUpdateDate: | 05/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.