Provider Demographics
NPI:1275017618
Name:THIBEDEAU, KATHRYN (MA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:THIBEDEAU
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 UNION STREET
Practice Address - Street 2:LYNN COMMUNITY HEALTH CENTER
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901
Practice Address - Country:US
Practice Address - Phone:781-477-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program