Provider Demographics
NPI:1154925642
Name:THIBEAULT, PAUL LESLIE (LMFT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LESLIE
Last Name:THIBEAULT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320844
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-0114
Mailing Address - Country:US
Mailing Address - Phone:415-225-3179
Mailing Address - Fax:
Practice Address - Street 1:14685 OKA RD SPC 51
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1903
Practice Address - Country:US
Practice Address - Phone:415-225-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122638106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist