Basic Information
| Provider Information | |||||||||
| NPI: | 1013226018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBEAULT | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336039 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397320 | ||||||||
| FaxNumber: | 4234397343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2010 | ||||||||
| LastUpdateDate: | 11/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6290 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3714470 | 01 | TN | GROUP MEDICARE | OTHER | 6007677 | 05 | NC | MEDICAID |