Provider Demographics
NPI:1619102183
Name:THIBODEAU, QUINN BLAKE (LPC, NCC, M COUN)
Entity Type:Individual
Prefix:
First Name:QUINN
Middle Name:BLAKE
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:LPC, NCC, M COUN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 GRANDVIEW CT
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2510
Mailing Address - Country:US
Mailing Address - Phone:208-681-7182
Mailing Address - Fax:
Practice Address - Street 1:1891 GRANDVIEW CT
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2510
Practice Address - Country:US
Practice Address - Phone:208-681-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4361101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker