Basic Information
| Provider Information | |||||||||
| NPI: | 1801004510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBODEAUX | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JUANITA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 E 76TH ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641312008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164446533 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 WESTOWNE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 66068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164071754 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2002024986 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.