Provider Demographics
NPI:1053982884
Name:PHAN, CAROLINE
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:PHAN
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 1:1263 PUNTA GORDA CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4861
Mailing Address - Country:US
Mailing Address - Phone:407-780-6699
Mailing Address - Fax:
Practice Address - Street 1:924 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1246
Practice Address - Country:US
Practice Address - Phone:321-247-5165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-23-63705103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113377300Medicaid