Provider Demographics
NPI:1912375676
Name:LY, HERTHAO (BASW)
Entity Type:Individual
Prefix:
First Name:HERTHAO
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:BASW
Other - Prefix:
Other - First Name:KIRBY
Other - Middle Name:
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3737 MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-5303
Mailing Address - Country:US
Mailing Address - Phone:916-480-1801
Mailing Address - Fax:916-854-1809
Practice Address - Street 1:3737 MARCONI AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5303
Practice Address - Country:US
Practice Address - Phone:916-480-1801
Practice Address - Fax:916-854-1809
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management