Provider Demographics
NPI:1871245027
Name:MOUA, CHAI
Entity Type:Individual
Prefix:
First Name:CHAI
Middle Name:
Last Name:MOUA
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 1:4701 RUDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7953
Mailing Address - Country:US
Mailing Address - Phone:715-590-2360
Mailing Address - Fax:
Practice Address - Street 1:4701 RUDOLPH RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7953
Practice Address - Country:US
Practice Address - Phone:715-590-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIM0001008722407Medicaid