Healthcare Provider Details

I. General information

NPI: 1811714421
Provider Name (Legal Business Name): LEE THAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 MEADOWLANDS DR
WHITE BEAR LK MN
55127-2339
US

IV. Provider business mailing address

1352 BURR ST
SAINT PAUL MN
55130-3406
US

V. Phone/Fax

Practice location:
  • Phone: 612-315-1976
  • Fax:
Mailing address:
  • Phone: 612-380-3293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: