Provider Demographics
NPI:1639454770
Name:THIBAULT, KENT (LMSW, CADC)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:LMSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 N 300 E
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-5451
Mailing Address - Country:US
Mailing Address - Phone:208-324-8284
Mailing Address - Fax:208-324-8284
Practice Address - Street 1:251 N 300 E
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-5451
Practice Address - Country:US
Practice Address - Phone:208-324-8284
Practice Address - Fax:208-324-8284
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-28571104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker