Provider Demographics
NPI:1730335787
Name:QUACH, PHUONG
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:QUACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3703
Mailing Address - Country:US
Mailing Address - Phone:619-756-1338
Mailing Address - Fax:
Practice Address - Street 1:1675 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3703
Practice Address - Country:US
Practice Address - Phone:619-756-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF57182106H00000X
CAMFC49103106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist