Healthcare Provider Details

I. General information

NPI: 1033025721
Provider Name (Legal Business Name): ANTHONY THIBODEAUX TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 W ANN ARBOR TRL STE 106
PLYMOUTH MI
48170-6262
US

IV. Provider business mailing address

5108 S MERRIMAN RD
WAYNE MI
48184-2228
US

V. Phone/Fax

Practice location:
  • Phone: 734-392-4130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362010380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: