Basic Information
| Provider Information | |||||||||
| NPI: | 1073055315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | JOURNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHAM | ||||||||
| OtherFirstName: | JOE NGON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3530 ATLANTIC AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908074569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624241886 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3530 ATLANTIC AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908074569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624241886 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2016 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 92555 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.