Provider Demographics
NPI:1710876065
Name:THIBAULT, CHASTIDY RAVEN
Entity type:Individual
Prefix:
First Name:CHASTIDY
Middle Name:RAVEN
Last Name:THIBAULT
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 1:7215 WEST SHIRE DR
Mailing Address - Street 2:LANSING
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917
Mailing Address - Country:US
Mailing Address - Phone:517-657-2638
Mailing Address - Fax:
Practice Address - Street 1:7215 WEST SHRIRE DR LANSING 48917
Practice Address - Street 2:LANSING
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917
Practice Address - Country:US
Practice Address - Phone:517-657-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician