Provider Demographics
NPI:1114131737
Name:PHAM, THU DAN THI (PHD)
Entity Type:Individual
Prefix:DR
First Name:THU
Middle Name:DAN THI
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:THU
Other - Middle Name:DAN
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1305 TOMMYDON ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 TOMMYDON ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3364
Practice Address - Country:US
Practice Address - Phone:209-476-5256
Practice Address - Fax:209-476-3528
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21326103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist