Provider Demographics
NPI:1457845992
Name:THIBODEAUX, SHANTELL REAUX
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:REAUX
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7608 LAKE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:ERATH
Mailing Address - State:LA
Mailing Address - Zip Code:70533-5452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7608 LAKE WOOD DR
Practice Address - Street 2:
Practice Address - City:ERATH
Practice Address - State:LA
Practice Address - Zip Code:70533-5452
Practice Address - Country:US
Practice Address - Phone:337-519-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty