Provider Demographics
NPI:1184061970
Name:THIBODEAUX, AMANDA CLARE
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:CLARE
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 1:108 ALONDA DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4221
Mailing Address - Country:US
Mailing Address - Phone:337-349-9987
Mailing Address - Fax:
Practice Address - Street 1:1000 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2436
Practice Address - Country:US
Practice Address - Phone:337-289-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA4329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist