Provider Demographics
NPI:1508028507
Name:THACH, PETER THAO (LCSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:THAO
Last Name:THACH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 RED HILL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5518
Mailing Address - Country:US
Mailing Address - Phone:949-267-0400
Mailing Address - Fax:949-221-0004
Practice Address - Street 1:2500 RED HILL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5518
Practice Address - Country:US
Practice Address - Phone:949-267-0400
Practice Address - Fax:949-221-0004
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CALCSW700651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator