Provider Demographics
NPI:1467105056
Name:LEE, MAI THONG
Entity Type:Individual
Prefix:
First Name:MAI THONG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAI
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAI LEE
Mailing Address - Street 1:2560 W SHAW LN STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2777
Mailing Address - Country:US
Mailing Address - Phone:559-443-4800
Mailing Address - Fax:
Practice Address - Street 1:2560 W SHAW LN STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2777
Practice Address - Country:US
Practice Address - Phone:559-443-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100360101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health