Provider Demographics
NPI:1083248561
Name:IV, THAI LEA
Entity Type:Individual
Prefix:
First Name:THAI
Middle Name:LEA
Last Name:IV
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 1:25 HATHAWAY ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-2753
Mailing Address - Country:US
Mailing Address - Phone:781-346-4413
Mailing Address - Fax:
Practice Address - Street 1:25 HATHAWAY ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905-2753
Practice Address - Country:US
Practice Address - Phone:781-346-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician