Provider Demographics
NPI:1063246940
Name:THIBAULT, LUKE
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 CASSIA CIR APT A
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2872
Mailing Address - Country:US
Mailing Address - Phone:352-232-4069
Mailing Address - Fax:
Practice Address - Street 1:1000 EMMETT ST STE 102
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3605
Practice Address - Country:US
Practice Address - Phone:352-232-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-31
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI73532355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant