Provider Demographics
NPI:1487434189
Name:THIBEAULT, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:THIBEAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 NOCTURNE RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293
Mailing Address - Country:US
Mailing Address - Phone:941-237-8080
Mailing Address - Fax:
Practice Address - Street 1:22655 BAYSHORE RD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2018
Practice Address - Country:US
Practice Address - Phone:239-351-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-300568106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician