Provider Demographics
NPI:1457010548
Name:PHAM, TINA
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
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:PO BOX 971
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91025-0971
Mailing Address - Country:US
Mailing Address - Phone:626-676-7615
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 971
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91025-0971
Practice Address - Country:US
Practice Address - Phone:626-604-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC11801101YM0800X
CAAMFT133254106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health