Provider Demographics
NPI:1750938940
Name:THIBAULT, RICHARD LOUIS JR
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LOUIS
Last Name:THIBAULT
Suffix:JR
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 1:15 WINTER ST APT 9
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-3865
Mailing Address - Country:US
Mailing Address - Phone:978-786-2788
Mailing Address - Fax:
Practice Address - Street 1:11 CIRCLE AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905-3050
Practice Address - Country:US
Practice Address - Phone:781-595-2413
Practice Address - Fax:781-596-0113
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)