Provider Demographics
NPI:1043758568
Name:THIBODEAIX, RANDY
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:THIBODEAIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 OCTAVIA DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583-4639
Mailing Address - Country:US
Mailing Address - Phone:337-962-7469
Mailing Address - Fax:
Practice Address - Street 1:209 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6256
Practice Address - Country:US
Practice Address - Phone:337-942-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist