Basic Information
| Provider Information | |||||||||
| NPI: | 1952456121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | KOY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | 101YM0800X | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAETURN | ||||||||
| OtherFirstName: | KOY | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | 101YM0800X | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3905 MACDONALD AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948052229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102337555 | ||||||||
| FaxNumber: | 5102334545 | ||||||||
| Practice Location | |||||||||
| Address1: | 3905 MACDONALD AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948052229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102337555 | ||||||||
| FaxNumber: | 5102334545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.