Provider Demographics
NPI:1396895652
Name:THAO, ELIZABETH (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:THAO
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19285 BLACK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6009
Mailing Address - Country:US
Mailing Address - Phone:262-786-5743
Mailing Address - Fax:
Practice Address - Street 1:155 E CAPITOL DR
Practice Address - Street 2:SUITE 5B
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2134
Practice Address - Country:US
Practice Address - Phone:414-688-2678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6854-123101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical