Provider Demographics
NPI:1568851905
Name:THIBEAU, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:THIBEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-4087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-4087
Practice Address - Country:US
Practice Address - Phone:207-469-6642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA388224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOA388Medicaid