Provider Demographics
NPI:1538110614
Name:THEODOR SHIBLES, LAURA (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:THEODOR SHIBLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:THEODOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:20 RESEARCH PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4214
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:860-510-0020
Practice Address - Street 1:10 LANGLEY RD
Practice Address - Street 2:STE 300
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-1972
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:860-510-0020
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7026103T00000X, 103TC0700X
NY009601103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W50115Medicare ID - Type Unspecified