Provider Demographics
NPI:1083828800
Name:THIBODEAU, LINDA ANN (LP)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:ANN
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 21ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-4397
Mailing Address - Country:US
Mailing Address - Phone:507-281-1265
Mailing Address - Fax:
Practice Address - Street 1:343 WOODLAKE DR SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6242
Practice Address - Country:US
Practice Address - Phone:507-287-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5227103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist