Provider Demographics
NPI:1629872767
Name:THIBODEAUX, KEVIN JAMES
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
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 1:225 CHAMPAGNE BLVD
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3733
Mailing Address - Country:US
Mailing Address - Phone:337-442-6506
Mailing Address - Fax:337-442-6505
Practice Address - Street 1:225 CHAMPAGNE BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3733
Practice Address - Country:US
Practice Address - Phone:337-442-6506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist