Provider Demographics
NPI:1609111384
Name:THIBAULT, BETH (LCPC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAIN ST STE 1508
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-3517
Mailing Address - Country:US
Mailing Address - Phone:207-494-8016
Mailing Address - Fax:207-494-8640
Practice Address - Street 1:110 MAIN ST STE 1508
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-3517
Practice Address - Country:US
Practice Address - Phone:207-494-8016
Practice Address - Fax:207-494-8640
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3377101YP2500X
MECC3993101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional