Healthcare Provider Details

I. General information

NPI: 1508028507
Provider Name (Legal Business Name): PETER THAO THACH L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 RED HILL AVE SUITE 100
SANTA ANA CA
92705-5518
US

IV. Provider business mailing address

2500 RED HILL AVE SUITE 100
SANTA ANA CA
92705-5518
US

V. Phone/Fax

Practice location:
  • Phone: 949-267-0400
  • Fax: 949-221-0004
Mailing address:
  • Phone: 949-267-0400
  • Fax: 949-221-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW70065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: