Provider Demographics
NPI:1568819704
Name:THIBODEAUX, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
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 1:9441 COMMON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1463
Mailing Address - Country:US
Mailing Address - Phone:225-923-3733
Mailing Address - Fax:225-923-3735
Practice Address - Street 1:9441 COMMON ST
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1463
Practice Address - Country:US
Practice Address - Phone:225-923-3733
Practice Address - Fax:225-923-3735
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC6670101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600964601Medicaid