Provider Demographics
NPI:1407962426
Name:THIBODEAUX HASLAM, KATHLEEN MARY (PT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:THIBODEAUX HASLAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 GILMER RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-2511
Mailing Address - Country:US
Mailing Address - Phone:903-297-0008
Mailing Address - Fax:903-297-0018
Practice Address - Street 1:2010 GILMER RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2511
Practice Address - Country:US
Practice Address - Phone:903-297-0008
Practice Address - Fax:903-297-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1143816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS85759Medicare UPIN