Basic Information
Provider Information
NPI: 1003141300
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NGO
FirstName: PHUONG
MiddleName:  
NamePrefix: MS.
NameSuffix:  
Credential: MSW INTERN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: NGO
OtherFirstName: SERENA
OtherMiddleName:  
OtherNamePrefix: MS.
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 1975 LONG BEACH BLVD FL 2
Address2:  
City: LONG BEACH
State: CA
PostalCode: 908065501
CountryCode: US
TelephoneNumber: 5625999401
FaxNumber:  
Practice Location
Address1: 1975 LONG BEACH BLVD FL 2
Address2:  
City: LONG BEACH
State: CA
PostalCode: 908065501
CountryCode: US
TelephoneNumber: 5625999401
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/05/2009
LastUpdateDate: 10/05/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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