Provider Demographics
NPI:1932329661
Name:THIBODEAUX, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
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 1:607 CASE TRL NW
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-9061
Mailing Address - Country:US
Mailing Address - Phone:601-757-5506
Mailing Address - Fax:
Practice Address - Street 1:20 THE RAYS TRL SE
Practice Address - Street 2:
Practice Address - City:BOGUE CHITTO
Practice Address - State:MS
Practice Address - Zip Code:39629-8500
Practice Address - Country:US
Practice Address - Phone:601-833-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2846235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07427004Medicaid