Provider Demographics
NPI:1134611775
Name:THIBODEAUX, ERICA LYNN (LPC)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E 4TH ST STE 307
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3509
Mailing Address - Country:US
Mailing Address - Phone:507-205-2405
Mailing Address - Fax:
Practice Address - Street 1:51 E 4TH ST STE 307
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3509
Practice Address - Country:US
Practice Address - Phone:507-205-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1924101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional