Healthcare Provider Details

I. General information

NPI: 1164492161
Provider Name (Legal Business Name): MARIA ERB THIBAULT PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 COLCHESTER AVE
BURLINGTON VT
05401-1417
US

IV. Provider business mailing address

80 COLCHESTER AVE
BURLINGTON VT
05401-1417
US

V. Phone/Fax

Practice location:
  • Phone: 802-657-7990
  • Fax: 802-859-8935
Mailing address:
  • Phone: 802-657-7990
  • Fax: 802-859-8935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number040-002463
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104-0000042
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: