Provider Demographics
NPI:1083141907
Name:BIBEAU, JEFFREY LEONARD (MAST)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LEONARD
Last Name:BIBEAU
Suffix:
Gender:M
Credentials:MAST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 FRUIT HILL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-2640
Mailing Address - Country:US
Mailing Address - Phone:401-353-3900
Mailing Address - Fax:401-354-7986
Practice Address - Street 1:429 FRUIT HILL AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-2640
Practice Address - Country:US
Practice Address - Phone:401-353-3900
Practice Address - Fax:401-354-7986
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty