Provider Demographics
NPI:1134848674
Name:THIBODEAUX, KOURTNEY (PSS)
Entity type:Individual
Prefix:MRS
First Name:KOURTNEY
Middle Name:
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5949
Mailing Address - Country:US
Mailing Address - Phone:337-602-6391
Mailing Address - Fax:337-602-6392
Practice Address - Street 1:1634 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5949
Practice Address - Country:US
Practice Address - Phone:337-602-6391
Practice Address - Fax:337-602-6392
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator