Provider Demographics
NPI:1083697270
Name:THIBAULT, GERALD W (LCPC)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:W
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BEECH STREET
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976
Mailing Address - Country:US
Mailing Address - Phone:207-474-3477
Mailing Address - Fax:
Practice Address - Street 1:157 WATERVILLE ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976
Practice Address - Country:US
Practice Address - Phone:207-474-3477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1829101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME274710099Medicaid