Basic Information
| Provider Information | |||||||||
| NPI: | 1366682023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAO | ||||||||
| FirstName: | PHENG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10586 E NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | SANGER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936579719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595794151 | ||||||||
| FaxNumber: | 5592654823 | ||||||||
| Practice Location | |||||||||
| Address1: | 2772 MARTIN LUTHER KING BLVD. | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592654800 | ||||||||
| FaxNumber: | 5592654823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2009 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | D7036245 | CA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.