Provider Demographics
NPI:1952825598
Name:VAN, IRENE PHUONG BAO
Entity Type:Individual
Prefix:
First Name:IRENE PHUONG
Middle Name:BAO
Last Name:VAN
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 1:2010 EL CAMINO REAL # 1392
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-4051
Mailing Address - Country:US
Mailing Address - Phone:408-284-9000
Mailing Address - Fax:
Practice Address - Street 1:1885 LUNDY AVE STE 223
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1888
Practice Address - Country:US
Practice Address - Phone:408-284-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA127828106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program