Provider Demographics
NPI:1790107597
Name:PHAM, PETERSON Q (ASW)
Entity Type:Individual
Prefix:
First Name:PETERSON
Middle Name:Q
Last Name:PHAM
Suffix:
Gender:M
Credentials:ASW
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 1789
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-1789
Mailing Address - Country:US
Mailing Address - Phone:657-206-0035
Mailing Address - Fax:
Practice Address - Street 1:12912 BROOKHURST ST STE 480
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4867
Practice Address - Country:US
Practice Address - Phone:714-636-6286
Practice Address - Fax:714-636-8354
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW85404OtherBOARD OF BEHAVIORAL SCIENCES