Provider Demographics
NPI:1922742980
Name:THIBODEAU, ADAM GERARD (LLMSW)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:GERARD
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5297 LANCASTER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4424
Mailing Address - Country:US
Mailing Address - Phone:313-452-5751
Mailing Address - Fax:
Practice Address - Street 1:120 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1975
Practice Address - Country:US
Practice Address - Phone:248-529-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511140721041C0700X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical