Provider Demographics
NPI:1073974309
Name:THET, CHARLAINE
Entity Type:Individual
Prefix:
First Name:CHARLAINE
Middle Name:
Last Name:THET
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 1:1426 FILLMORE ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-5236
Mailing Address - Country:US
Mailing Address - Phone:415-694-2894
Mailing Address - Fax:
Practice Address - Street 1:1426 FILLMORE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-5236
Practice Address - Country:US
Practice Address - Phone:415-694-2894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist