Provider Demographics
NPI:1992424154
Name:THAO, CHIN (LICSW)
Entity type:Individual
Prefix:
First Name:CHIN
Middle Name:
Last Name:THAO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 MOORE LAKE DR E STE 152
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5135
Mailing Address - Country:US
Mailing Address - Phone:651-399-7023
Mailing Address - Fax:
Practice Address - Street 1:1250 MOORE LAKE DR E STE 152
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5135
Practice Address - Country:US
Practice Address - Phone:612-389-2332
Practice Address - Fax:612-389-2332
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN263711041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical