Provider Demographics
NPI:1558011619
Name:THA, MAUNG PHONE MYAT
Entity Type:Individual
Prefix:
First Name:MAUNG
Middle Name:PHONE MYAT
Last Name:THA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PHONE
Other - Middle Name:
Other - Last Name:THA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1151 DOVE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 DOVE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2840
Practice Address - Country:US
Practice Address - Phone:949-630-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician