Provider Demographics
NPI:1548008162
Name:THIBODEAUX, SAMUEL ELIJAH
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ELIJAH
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16662 IRBY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4919
Mailing Address - Country:US
Mailing Address - Phone:737-318-5140
Mailing Address - Fax:
Practice Address - Street 1:601 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4521
Practice Address - Country:US
Practice Address - Phone:714-908-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008210973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)