Provider Demographics
NPI:1033505656
Name:PHAN, KATIE G (MS)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:G
Last Name:PHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:G
Other - Last Name:SOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:169 SAXONY RD STE 111
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:169 SAXONY RD STE 111
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6779
Practice Address - Country:US
Practice Address - Phone:858-751-9906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist