Healthcare Provider Details

I. General information

NPI: 1598621674
Provider Name (Legal Business Name): CHRISTINE M THIBEAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2026
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PINE CT
CROMWELL CT
06416-1734
US

IV. Provider business mailing address

16 PINE CT
CROMWELL CT
06416-1734
US

V. Phone/Fax

Practice location:
  • Phone: 860-529-0880
  • Fax:
Mailing address:
  • Phone: 860-529-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number000126
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: