Provider Demographics
NPI:1801870001
Name:THEBEAU, MARLENE (PT)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:THEBEAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01524-1507
Mailing Address - Country:US
Mailing Address - Phone:508-892-1335
Mailing Address - Fax:508-892-1780
Practice Address - Street 1:2 GROVE ST
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:MA
Practice Address - Zip Code:01524-1507
Practice Address - Country:US
Practice Address - Phone:508-892-1335
Practice Address - Fax:508-892-1780
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68925Medicare ID - Type Unspecified