Basic Information
| Provider Information | |||||||||
| NPI: | 1891083481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | PHUONG | ||||||||
| MiddleName: | MAI | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NGUYEN | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | MAI | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD, LADC, MFT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 HARVARD WAY | ||||||||
| Address2: | MAIL STOP T5 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 KIRMAN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759822862 | ||||||||
| FaxNumber: | 7759822865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2011 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CADC-I#01075 | NV | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | NV | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MFT-I#MI0417 | NV | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | 01318 | NV | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.