Basic Information
| Provider Information | |||||||||
| NPI: | 1750938940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBAULT | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 WINTER ST APT 9 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019703865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787862788 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 CIRCLE AVE | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019053050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815952413 | ||||||||
| FaxNumber: | 7815960113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2019 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.