Healthcare Provider Details

I. General information

NPI: 1265757470
Provider Name (Legal Business Name): EMTHIBODEAU, LICSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 NEW DURHAM RD
ALTON NH
03809-4923
US

IV. Provider business mailing address

330 NEW DURHAM RD
ALTON NH
03809-4923
US

V. Phone/Fax

Practice location:
  • Phone: 603-941-4878
  • Fax: 603-941-0410
Mailing address:
  • Phone: 603-941-4878
  • Fax: 603-941-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1328
License Number StateNH

VIII. Authorized Official

Name: ESTELLE M THIBODEAU
Title or Position: OWNER
Credential: LICSW
Phone: 603-941-4878