Provider Demographics
NPI:1225171242
Name:PHAM, TINA-VANTHI THI
Entity Type:Individual
Prefix:
First Name:TINA-VANTHI
Middle Name:THI
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 1:934 N MOUNTAIN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3659
Mailing Address - Country:US
Mailing Address - Phone:909-579-8100
Mailing Address - Fax:909-579-8149
Practice Address - Street 1:934 N MOUNTAIN AVE STE C
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3659
Practice Address - Country:US
Practice Address - Phone:909-579-8100
Practice Address - Fax:909-579-8149
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health