Provider Demographics
NPI:1649414368
Name:THIBODEAUX, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 SCENIC WAY
Mailing Address - Street 2:
Mailing Address - City:ETOILE
Mailing Address - State:TX
Mailing Address - Zip Code:75944-7662
Mailing Address - Country:US
Mailing Address - Phone:936-404-0843
Mailing Address - Fax:
Practice Address - Street 1:2604 US HIGHWAY 69 N
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-1060
Practice Address - Country:US
Practice Address - Phone:936-899-7235
Practice Address - Fax:936-899-7237
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2070212225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty