Provider Demographics
NPI:1508546490
Name:PHAM, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:817-217-9074
Mailing Address - Fax:
Practice Address - Street 1:4121 SAN ANTONIO ST APT 112
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-2469
Practice Address - Country:US
Practice Address - Phone:817-217-9074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician