Provider Demographics
NPI:1841382181
Name:NGUYEN, CONG TAM NGOC
Entity Type:Individual
Prefix:
First Name:CONG TAM
Middle Name:NGOC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TAM
Other - Middle Name:NGOC CONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1136 S FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-2944
Mailing Address - Country:US
Mailing Address - Phone:213-321-5558
Mailing Address - Fax:
Practice Address - Street 1:210 S DE LACEY AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2048
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor