Provider Demographics
NPI:1568018786
Name:PHAM, LISA KIM (MSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KIM
Last Name:PHAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E CHAPMAN AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3846
Mailing Address - Country:US
Mailing Address - Phone:714-680-9000
Mailing Address - Fax:
Practice Address - Street 1:801 E CHAPMAN AVE STE 203
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2024-12-11
Deactivation Date:2020-06-04
Deactivation Code:
Reactivation Date:2020-06-09
Provider Licenses
StateLicense IDTaxonomies
CA1247941041C0700X
CA390200000X390200000X
CA95354101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program