Provider Demographics
NPI:1275116055
Name:PHAN, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PHAN
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 1:15619 S WILTON PL
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4732
Mailing Address - Country:US
Mailing Address - Phone:310-877-3355
Mailing Address - Fax:
Practice Address - Street 1:15619 S WILTON PL
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4732
Practice Address - Country:US
Practice Address - Phone:310-877-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-06-30
Deactivation Date:2021-05-06
Deactivation Code:
Reactivation Date:2021-06-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician