Provider Demographics
NPI:1295915601
Name:LY, KA BAO (MSW)
Entity type:Individual
Prefix:
First Name:KA
Middle Name:BAO
Last Name:LY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 SOUTH FREEDOM ROAD STK 118
Mailing Address - Street 2:
Mailing Address - City:FRENCH CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95231-9693
Mailing Address - Country:US
Mailing Address - Phone:209-463-3400
Mailing Address - Fax:
Practice Address - Street 1:7777 SOUTH FREEDOM ROAD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-4305
Practice Address - Country:US
Practice Address - Phone:209-946-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA62056104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker