Provider Demographics
NPI:1235697384
Name:THIBODEAUX, KERRY (LPC)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E PINHOOK RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-8610
Mailing Address - Country:US
Mailing Address - Phone:337-521-7580
Mailing Address - Fax:337-521-7581
Practice Address - Street 1:700 SAINT LANDRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4630
Practice Address - Country:US
Practice Address - Phone:337-210-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3491101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional