Healthcare Provider Details

I. General information

NPI: 1508785650
Provider Name (Legal Business Name): LYLAH THAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 S FRONT ST STE 2
MANKATO MN
56001-3887
US

IV. Provider business mailing address

175 BALCERZAK DR APT 1
MANKATO MN
56001-5739
US

V. Phone/Fax

Practice location:
  • Phone: 507-304-7020
  • Fax:
Mailing address:
  • Phone: 612-598-5017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: