Provider Demographics
NPI:1699324152
Name:PHANICHKARN, BRIAN (LCSW)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PHANICHKARN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17247 VIA EL CERRITO
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-2736
Mailing Address - Country:US
Mailing Address - Phone:415-795-0737
Mailing Address - Fax:
Practice Address - Street 1:39180 LIBERTY ST STE 220
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1522
Practice Address - Country:US
Practice Address - Phone:415-735-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA907881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical