Provider Demographics
NPI:1922159383
Name:THIBODEAU, KRISTY (MS, PT)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:MA
Mailing Address - Zip Code:02766-2436
Mailing Address - Country:US
Mailing Address - Phone:508-285-5533
Mailing Address - Fax:508-285-7977
Practice Address - Street 1:250 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:MA
Practice Address - Zip Code:02766-2436
Practice Address - Country:US
Practice Address - Phone:508-285-5533
Practice Address - Fax:508-285-7977
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11491609OtherAETNA
MAY68454OtherBCBSMA
MAY69591Medicare ID - Type UnspecifiedPHYSICAL THERAPIST