Healthcare Provider Details

I. General information

NPI: 1225252968
Provider Name (Legal Business Name): GE THAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 MILES CT STE B
MERCED CA
95348-4300
US

IV. Provider business mailing address

1748 MILES CT STE B
MERCED CA
95348-4300
US

V. Phone/Fax

Practice location:
  • Phone: 209-819-9974
  • Fax: 209-384-7384
Mailing address:
  • Phone: 209-819-9974
  • Fax: 209-384-7384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW29656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: