Provider Demographics
NPI:1346372703
Name:PHAM, MAI TAN (CLINICAL SOCIAL WORK)
Entity Type:Individual
Prefix:MS
First Name:MAI
Middle Name:TAN
Last Name:PHAM
Suffix:
Gender:F
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2060 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1001
Mailing Address - Country:US
Mailing Address - Phone:510-346-1496
Mailing Address - Fax:510-346-7521
Practice Address - Street 1:2060 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1001
Practice Address - Country:US
Practice Address - Phone:510-346-1496
Practice Address - Fax:510-346-7521
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA642301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical