Provider Demographics
NPI:1972241487
Name:PHAN, THAO THI (LMSW-C)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:THI
Last Name:PHAN
Suffix:
Gender:F
Credentials:LMSW-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW-C
Mailing Address - Street 1:2146 PEACHTREE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-1464
Mailing Address - Country:US
Mailing Address - Phone:734-218-0922
Mailing Address - Fax:734-629-0448
Practice Address - Street 1:23100 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2756
Practice Address - Country:US
Practice Address - Phone:586-335-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011144031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical