Provider Demographics
NPI:1205179827
Name:THIBAULT, ROLAND (LADC)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-2212
Mailing Address - Country:US
Mailing Address - Phone:207-934-5231
Mailing Address - Fax:
Practice Address - Street 1:28 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-2212
Practice Address - Country:US
Practice Address - Phone:207-934-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4284101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME137990000Medicare UPIN