Healthcare Provider Details

I. General information

NPI: 1417018482
Provider Name (Legal Business Name): ADLY THEBAUD,MD,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 REBECCA LN STE 107
ORANGE CITY FL
32763-8350
US

IV. Provider business mailing address

2725 REBECCA LN STE 107
ORANGE CITY FL
32763-8350
US

V. Phone/Fax

Practice location:
  • Phone: 386-775-0736
  • Fax: 386-775-0738
Mailing address:
  • Phone: 386-775-0736
  • Fax: 386-775-0738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME60436
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP 9410846
License Number StateFL

VIII. Authorized Official

Name: ADLY THEBAUD
Title or Position: OWNER/PROVIDER
Credential:
Phone: 386-775-0736