Provider Demographics
NPI:1245327071
Name:PHAN, KIM NGUYEN (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:NGUYEN
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26345 YOLANDA ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3114
Mailing Address - Country:US
Mailing Address - Phone:949-831-1394
Mailing Address - Fax:
Practice Address - Street 1:12966 EUCLID ST
Practice Address - Street 2:SUITE 515
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-5200
Practice Address - Country:US
Practice Address - Phone:714-227-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical