Provider Demographics
NPI:1609977065
Name:THIBODEAU, SHEILA (LCSW, CCS)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:LCSW, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 REINZO LN
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2665
Mailing Address - Country:US
Mailing Address - Phone:207-299-3265
Mailing Address - Fax:207-941-9333
Practice Address - Street 1:193 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6507
Practice Address - Country:US
Practice Address - Phone:207-299-3265
Practice Address - Fax:207-941-9333
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LC61351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202720099Medicaid
ME1583Medicare ID - Type Unspecified