Provider Demographics
NPI:1609831577
Name:THIBEAULT, MICHELLE L (PT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:THIBEAULT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4806
Mailing Address - Country:US
Mailing Address - Phone:203-630-3939
Mailing Address - Fax:
Practice Address - Street 1:1260 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4806
Practice Address - Country:US
Practice Address - Phone:203-630-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist