Provider Demographics
NPI:1710583620
Name:THIBEAULT, PHYLICIA LEE
Entity Type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:LEE
Last Name:THIBEAULT
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 1:22 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-4302
Mailing Address - Country:US
Mailing Address - Phone:508-676-1307
Mailing Address - Fax:
Practice Address - Street 1:22 FRONT ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-4302
Practice Address - Country:US
Practice Address - Phone:508-676-1307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)