Provider Demographics
NPI:1366682023
Name:THAO, PHENG
Entity Type:Individual
Prefix:
First Name:PHENG
Middle Name:
Last Name:THAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10586 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-9719
Mailing Address - Country:US
Mailing Address - Phone:559-579-4151
Mailing Address - Fax:559-265-4823
Practice Address - Street 1:2772 MARTIN LUTHER KING BLVD.
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:559-265-4823
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7036245101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor