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General NPI Number Information
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NPI Number | 1063246940
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Entity Type | Individual
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Provider Name | LUKE THIBAULT
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Gender | Male
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Dates
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Enumeration Date | 08/31/2024
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Last Update Date | 02/19/2025
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Provider Practice Location Address
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Address Line | 1000 EMMETT ST STE 102
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City | KISSIMMEE
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State | FL
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Zip | 34741-3605
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Country | US
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Telephone | 352-232-4069
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Fax |
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Provider Business Mailing Address
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Address Line | 2105 CASSIA CIR APT A
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City | KISSIMMEE
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State | FL
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Zip | 34741-2872
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Country | US
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Telephone | 352-232-4069
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number | SI7353
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License Number State | FL
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