Provider Demographics
NPI:1003786807
Name:PHAN, THAO NGOC PHUONG
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:NGOC PHUONG
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3234 DELTA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2633
Mailing Address - Country:US
Mailing Address - Phone:626-776-7397
Mailing Address - Fax:626-776-7397
Practice Address - Street 1:1000 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-759-9154
Practice Address - Fax:626-759-9154
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty