Provider Demographics
NPI:1114231669
Name:PHAM, KELLY T
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:T
Last Name:PHAM
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 1:1015 12TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0838
Mailing Address - Country:US
Mailing Address - Phone:209-496-2327
Mailing Address - Fax:
Practice Address - Street 1:1015 12TH ST STE 2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0838
Practice Address - Country:US
Practice Address - Phone:209-496-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY29070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program