Healthcare Provider Details

I. General information

NPI: 1467308593
Provider Name (Legal Business Name): KEAMALYVON THAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
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: 209-384-7384
  • Fax: 209-384-1911
Mailing address:
  • Phone: 209-384-7384
  • Fax: 209-384-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: