Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | 83594 | CA |
Y | 104100000X | Social Worker | 100441 | CA |
NPI | 1003269051 |
---|---|
Provider Name | Corrine Thanh Ngoc Phan |
First Address | San Diego, CA 92102 |
Second Address | San Diego, CA 92102-4500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2016 |
Last Update Date | 21/10/2021 |