Provider Demographics
NPI:1578929600
Name:THIBODEAU, LISA CHRISTINE (129741-121)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINE
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:129741-121
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 DORSET LN
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-2452
Mailing Address - Country:US
Mailing Address - Phone:715-410-6772
Mailing Address - Fax:
Practice Address - Street 1:1752 DORSET LN
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2452
Practice Address - Country:US
Practice Address - Phone:715-410-6772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129741-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker