Provider Demographics
NPI:1306662275
Name:THIBODEAU, GRACE LYNN
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LYNN
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6228 FILBERT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-4106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6228 FILBERT AVE STE 3
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4106
Practice Address - Country:US
Practice Address - Phone:845-814-2642
Practice Address - Fax:888-915-5559
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician