Provider Demographics
NPI:1093921488
Name:PHAN, THAO MAI (MA, MS)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:MAI
Last Name:PHAN
Suffix:
Gender:F
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14101 W HWY 290 STE 700A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-9330
Mailing Address - Country:US
Mailing Address - Phone:512-650-3925
Mailing Address - Fax:
Practice Address - Street 1:14101 W HWY 290
Practice Address - Street 2:SUITE 700A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-9330
Practice Address - Country:US
Practice Address - Phone:512-650-3925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200993106H00000X
TX61700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional