Basic Information
| Provider Information | |||||||||
| NPI: | 1447703129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBODEAUX | ||||||||
| FirstName: | TONETTE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MAC/MHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THIBODEAUX | ||||||||
| OtherFirstName: | TONETTE | ||||||||
| OtherMiddleName: | BOXIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MAC/MHP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 311 MACARTHUR DR | ||||||||
| Address2: | |||||||||
| City: | SUNSET | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705846212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376623737 | ||||||||
| FaxNumber: | 3376623636 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 MACARTHUR DR | ||||||||
| Address2: | |||||||||
| City: | SUNSET | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705846212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376623737 | ||||||||
| FaxNumber: | 3376623636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2016 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.