Provider Demographics
NPI:1215404017
Name:PHUNG, ANDY (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 ROCKHOLD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2778
Mailing Address - Country:US
Mailing Address - Phone:626-248-0495
Mailing Address - Fax:
Practice Address - Street 1:3002 DOW AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7233
Practice Address - Country:US
Practice Address - Phone:714-731-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19632225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist