Provider Demographics
NPI:1295078426
Name:THIBODAUX, BRENT M (LAC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:THIBODAUX
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 BELLEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-5351
Mailing Address - Country:US
Mailing Address - Phone:985-399-3330
Mailing Address - Fax:985-399-3332
Practice Address - Street 1:1271 BELLEVIEW ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-5351
Practice Address - Country:US
Practice Address - Phone:985-399-3330
Practice Address - Fax:985-399-3332
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-06
Last Update Date:2013-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1240101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)