Provider Demographics
NPI:1417018482
Name:ADLY THEBAUD,MD,PA
Entity Type:Organization
Organization Name:ADLY THEBAUD,MD,PA
Other - Org Name:FAMILY PSYCHIATRY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADLY
Authorized Official - Middle Name:
Authorized Official - Last Name:THEBAUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-775-0736
Mailing Address - Street 1:2725 REBECCA LN STE 107
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8350
Mailing Address - Country:US
Mailing Address - Phone:386-775-0736
Mailing Address - Fax:386-775-0738
Practice Address - Street 1:2725 REBECCA LN STE 107
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8350
Practice Address - Country:US
Practice Address - Phone:386-775-0736
Practice Address - Fax:386-775-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME604362084P0804X
FL251S00000X, 251S00000X
FLARNP 9231203363LP0808X
FLARNP 9410846363LP0808X, 363LP0808X
FLARNP 9194440363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0231OtherMEDICARE
FL010364600Medicaid