Provider Demographics
NPI:1851833172
Name:LAO, EDWIN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:LAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 S AMPHLETT BLVD
Mailing Address - Street 2:314
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2703
Mailing Address - Country:US
Mailing Address - Phone:650-242-0179
Mailing Address - Fax:650-242-8202
Practice Address - Street 1:225 37TH AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4324
Practice Address - Country:US
Practice Address - Phone:650-242-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician