Provider Demographics
NPI:1235546979
Name:PHAM, PHONG (BCBA)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CAMBRIDGEPARK DR STE 301
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2392
Mailing Address - Country:US
Mailing Address - Phone:857-919-4493
Mailing Address - Fax:
Practice Address - Street 1:125 CAMBRIDGEPARK DR STE 301
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2392
Practice Address - Country:US
Practice Address - Phone:857-919-4493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1617103K00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172V00000XOther Service ProvidersCommunity Health Worker