Provider Demographics
NPI:1881027720
Name:THIBEAULT, MATTHEW ALEXANDER
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:THIBEAULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 S SIERRA AVE UNIT 1172
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-8048
Mailing Address - Country:US
Mailing Address - Phone:760-935-6522
Mailing Address - Fax:760-935-6522
Practice Address - Street 1:7901 FROST ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2701
Practice Address - Country:US
Practice Address - Phone:760-935-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30494103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical