Provider Demographics
NPI:1497097950
Name:PHAN, TIEN VANG (MA)
Entity type:Individual
Prefix:MISS
First Name:TIEN
Middle Name:VANG
Last Name:PHAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:TIEN
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5663 BALBOA AVE STE 380
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7228 HYATT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6102
Practice Address - Country:US
Practice Address - Phone:858-330-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32425103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health