Provider Demographics
NPI:1336465756
Name:THAI, NAM PHUONG (LCSW)
Entity Type:Individual
Prefix:
First Name:NAM
Middle Name:PHUONG
Last Name:THAI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 ALEXIAN DR STE C
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1901
Mailing Address - Country:US
Mailing Address - Phone:408-272-6081
Mailing Address - Fax:408-272-6088
Practice Address - Street 1:2101 ALEXIAN DR STE C
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1901
Practice Address - Country:US
Practice Address - Phone:408-272-6081
Practice Address - Fax:408-272-6088
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS253741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA168385Medicaid