Provider Demographics
NPI:1649931429
Name:THIBODEAU, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THIBODEAU
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 1:27 LITTLE MOHAWK RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:01370-9691
Mailing Address - Country:US
Mailing Address - Phone:413-312-8979
Mailing Address - Fax:
Practice Address - Street 1:329 CONWAY ST STE 1
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-1514
Practice Address - Country:US
Practice Address - Phone:413-774-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst