Provider Demographics
NPI:1730752239
Name:PHAN, TUAN
Entity type:Individual
Prefix:MR
First Name:TUAN
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 E SAN JACINTO AVE
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2878
Mailing Address - Country:US
Mailing Address - Phone:951-600-6350
Mailing Address - Fax:
Practice Address - Street 1:308 E SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2878
Practice Address - Country:US
Practice Address - Phone:951-600-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW124132104100000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker