Provider Demographics
NPI:1568211712
Name:PHAM, TAVA TINA
Entity type:Individual
Prefix:
First Name:TAVA
Middle Name:TINA
Last Name:PHAM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-1603
Mailing Address - Country:US
Mailing Address - Phone:908-397-5550
Mailing Address - Fax:
Practice Address - Street 1:705 CROSS ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4029
Practice Address - Country:US
Practice Address - Phone:212-481-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician