Provider Demographics
NPI:1700081320
Name:PHAM, KHANH QUANG (MFT)
Entity Type:Individual
Prefix:MR
First Name:KHANH
Middle Name:QUANG
Last Name:PHAM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 ENBORG CT
Mailing Address - Street 2:UNIT 100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:871 ENBORG CT
Practice Address - Street 2:UNIT 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2645
Practice Address - Country:US
Practice Address - Phone:408-885-8579
Practice Address - Fax:408-885-7544
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37003106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist