=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487434189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA THIBEAULT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2023
-----------------------------------------------------
Last Update Date | 12/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22655 BAYSHORE RD
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33980-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-351-4787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3265 NOCTURNE RD
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-237-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-23-300568
-----------------------------------------------------
License Number State |
-----------------------------------------------------