Provider Demographics
NPI:1164040911
Name:THIBODEAU, STEPHANIE KATHERINE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KATHERINE
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SUNNYSIDE ST
Mailing Address - Street 2:
Mailing Address - City:YANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06389-1010
Mailing Address - Country:US
Mailing Address - Phone:860-984-3579
Mailing Address - Fax:
Practice Address - Street 1:63 SUNNYSIDE ST
Practice Address - Street 2:
Practice Address - City:YANTIC
Practice Address - State:CT
Practice Address - Zip Code:06389-1010
Practice Address - Country:US
Practice Address - Phone:860-984-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health