Provider Demographics
NPI:1073542791
Name:LE, MINH-THU THI (PHD)
Entity Type:Individual
Prefix:
First Name:MINH-THU
Middle Name:THI
Last Name:LE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16787 BEACH BLVD
Mailing Address - Street 2:#711
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4848
Mailing Address - Country:US
Mailing Address - Phone:310-869-1050
Mailing Address - Fax:714-379-0187
Practice Address - Street 1:3415 S SEPULVEDA BLVD
Practice Address - Street 2:FL 11
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6060
Practice Address - Country:US
Practice Address - Phone:310-869-1050
Practice Address - Fax:714-379-0187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15571103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15571AMedicare ID - Type Unspecified
CAS70044Medicare UPIN