Healthcare Provider Details

I. General information

NPI: 1255775011
Provider Name (Legal Business Name): ELIZABETH C THIBODEAUX LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH C JOHNSTON

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-7209
US

IV. Provider business mailing address

3149 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-7209
US

V. Phone/Fax

Practice location:
  • Phone: 337-706-3415
  • Fax:
Mailing address:
  • Phone: 337-706-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13989
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: