Provider Demographics
NPI:1609183748
Name:THAO, CRYSTAL (LCSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:THAO
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 1:10048 TIVOLI DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-3115
Mailing Address - Country:US
Mailing Address - Phone:530-282-9969
Mailing Address - Fax:
Practice Address - Street 1:300 PULLMAN ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-9756
Practice Address - Country:US
Practice Address - Phone:925-872-3259
Practice Address - Fax:925-294-7202
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA883491041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator