Provider Demographics
NPI:1508664293
Name:THIBODEAUX, KALEB M (PMHNP)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:M
Last Name:THIBODEAUX
Suffix:
Gender:
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:
Practice Address - Street 1:203 ALLENDALE DR
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-3219
Practice Address - Country:US
Practice Address - Phone:225-389-1311
Practice Address - Fax:225-389-1330
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA239936363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health