Provider Demographics
NPI:1689397283
Name:PHAM, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
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 1:3131 W OAK RIDGE RD
Mailing Address - Street 2:BLDG 1 APT 10
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809
Mailing Address - Country:US
Mailing Address - Phone:407-233-9151
Mailing Address - Fax:
Practice Address - Street 1:730 SAND LAKE RD STE 176
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7747
Practice Address - Country:US
Practice Address - Phone:407-412-6114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician