Provider Demographics
NPI:1043649411
Name:PHAN, TATUM K (PHD)
Entity Type:Individual
Prefix:DR
First Name:TATUM
Middle Name:K
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHIELDS AVE
Mailing Address - Street 2:STUDENT HEALTH & COUNSELING SERVICES - UC DAVIS
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5270
Mailing Address - Country:US
Mailing Address - Phone:530-752-0871
Mailing Address - Fax:
Practice Address - Street 1:1 SHIELDS AVE
Practice Address - Street 2:STUDENT HEALTH & COUNSELING SERVICES - UC DAVIS
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5270
Practice Address - Country:US
Practice Address - Phone:530-752-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26065103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling