Provider Demographics
NPI:1932877578
Name:PHAN, SAMUEL KHOA (ASW)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KHOA
Last Name:PHAN
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 E BALL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5157
Mailing Address - Country:US
Mailing Address - Phone:714-517-6300
Mailing Address - Fax:
Practice Address - Street 1:2035 E BALL RD STE 200
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5157
Practice Address - Country:US
Practice Address - Phone:714-517-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW116794104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker