Provider Demographics
NPI:1578012175
Name:THIBODEAU, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:THIBODEAU
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 1:6940 SEA CORAL DR APT 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-8044
Mailing Address - Country:US
Mailing Address - Phone:207-944-7065
Mailing Address - Fax:
Practice Address - Street 1:1414 S DENVER AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-3423
Practice Address - Country:US
Practice Address - Phone:918-949-9871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist