Provider Demographics
NPI:1982185484
Name:PHAM, CASSIDY PHUONG
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:PHUONG
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 1:1917 W RED FOX RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7159
Mailing Address - Country:US
Mailing Address - Phone:714-519-6408
Mailing Address - Fax:
Practice Address - Street 1:4445 EASTGATE MALL STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1979
Practice Address - Country:US
Practice Address - Phone:866-478-3978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT107039106H00000X
CALMFT128739106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist