Provider Demographics
NPI:1215484498
Name:LY, VAN T
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:T
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 FORTRAN CT STE 136
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2318
Mailing Address - Country:US
Mailing Address - Phone:415-944-9595
Mailing Address - Fax:
Practice Address - Street 1:4423 FORTRAN CT STE 136
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2318
Practice Address - Country:US
Practice Address - Phone:415-944-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health