Provider Demographics
NPI:1609203868
Name:THAO LAO, PEGGY (LICSW)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:THAO LAO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14591 PERIDOT ST NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-3911
Mailing Address - Country:US
Mailing Address - Phone:763-898-7888
Mailing Address - Fax:
Practice Address - Street 1:1566 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1865
Practice Address - Country:US
Practice Address - Phone:763-898-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN187071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical