Basic Information
| Provider Information | |||||||||
| NPI: | 1245665447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | PHUONG KHANH | ||||||||
| MiddleName: | QUY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | ASW REGISTERED | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LE | ||||||||
| OtherFirstName: | KRISTY | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10200 FERN AVE | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906801711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142309110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 605 W OLYMPIC BLVD STE 550 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900151474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135531850 | ||||||||
| FaxNumber: | 2133833146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2013 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | ASW62481 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | ASW62481 | CA | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.