Provider Demographics
NPI:1497817316
Name:PHAM, MARCIE BEASLEY (MA)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:BEASLEY
Last Name:PHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 DOVE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2838
Mailing Address - Country:US
Mailing Address - Phone:949-877-4872
Mailing Address - Fax:
Practice Address - Street 1:1001 DOVE ST STE 105
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2838
Practice Address - Country:US
Practice Address - Phone:949-877-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47715106H00000X, 106H00000X
TNLMT0000000921106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist