Provider Demographics
NPI:1427878719
Name:THAO, MAI VANG
Entity type:Individual
Prefix:
First Name:MAI VANG
Middle Name:
Last Name:THAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12522 BLUE STEM TRL
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53108-9797
Mailing Address - Country:US
Mailing Address - Phone:414-207-2536
Mailing Address - Fax:
Practice Address - Street 1:2603 W RAWSON AVE STE 132
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8422
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician