Provider Demographics
NPI:1003651035
Name:THIBODEAU, ANNICK STEPHANIE
Entity type:Individual
Prefix:
First Name:ANNICK
Middle Name:STEPHANIE
Last Name:THIBODEAU
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 1:1613 DUBIEL DR
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-4212
Mailing Address - Country:US
Mailing Address - Phone:512-222-4072
Mailing Address - Fax:
Practice Address - Street 1:1613 DUBIEL DR
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-4212
Practice Address - Country:US
Practice Address - Phone:512-222-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113107225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist