Provider Demographics
NPI:1306135330
Name:THIBAULT, HILARY (PTA)
Entity type:Individual
Prefix:
First Name:HILARY
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BRISTOL ST N
Mailing Address - Street 2:SUITE #25
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8916
Mailing Address - Country:US
Mailing Address - Phone:949-250-1112
Mailing Address - Fax:
Practice Address - Street 1:1000 BRISTOL ST N
Practice Address - Street 2:SUITE #25
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8916
Practice Address - Country:US
Practice Address - Phone:949-250-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT9045225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant