Provider Demographics
NPI:1164600268
Name:THIBEAULT, TRINA K
Entity Type:Individual
Prefix:
First Name:TRINA
Middle Name:K
Last Name:THIBEAULT
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 1:226 STATE ROAD 19
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559-9796
Mailing Address - Country:US
Mailing Address - Phone:920-227-8123
Mailing Address - Fax:
Practice Address - Street 1:226 STATE ROAD 19
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9796
Practice Address - Country:US
Practice Address - Phone:920-227-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2025-027224Z00000X
WI5354-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant