Provider Demographics
NPI:1023770146
Name:PHAN, CAROLYN CHU (PT, DPT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:CHU
Last Name:PHAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11582 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-1632
Mailing Address - Country:US
Mailing Address - Phone:714-782-8423
Mailing Address - Fax:
Practice Address - Street 1:14120 BEACH BLVD STE 225
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4497
Practice Address - Country:US
Practice Address - Phone:866-303-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist