Healthcare Provider Details

I. General information

NPI: 1245165141
Provider Name (Legal Business Name): HARRY THIBAULT PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E MAIN ST STE 1
NILES MI
49120-2388
US

IV. Provider business mailing address

1506 BOND ST
NILES MI
49120-4057
US

V. Phone/Fax

Practice location:
  • Phone: 269-663-2201
  • Fax: 269-663-2209
Mailing address:
  • Phone: 574-292-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501006882
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: