Provider Demographics
NPI:1063485761
Name:THIBODEAU, EDWARD JOSEPH (MSSA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:MSSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5234 OVERLOOK LN
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-9111
Mailing Address - Country:US
Mailing Address - Phone:585-331-9320
Mailing Address - Fax:
Practice Address - Street 1:5234 OVERLOOK LN
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-9111
Practice Address - Country:US
Practice Address - Phone:585-331-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-12
Last Update Date:2010-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC048887001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical