Healthcare Provider Details

I. General information

NPI: 1497625503
Provider Name (Legal Business Name): THAI YANG LPC-IT, SAC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 CALUMET DR
SHEBOYGAN WI
53083-3839
US

IV. Provider business mailing address

520 PINE RIDGE AVE
HOWARDS GROVE WI
53083-2246
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-6908
  • Fax:
Mailing address:
  • Phone: 920-242-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21010-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8782-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: