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General NPI Number Information
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NPI Number | 1619102183
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Entity Type | Individual
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Provider Name | QUINN BLAKE THIBODEAU LPC, NCC, M. COUN
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Gender | Male
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Dates
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Enumeration Date | 05/27/2009
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Last Update Date | 08/12/2009
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Provider Practice Location Address
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Address Line | 1891 GRANDVIEW CT
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City | IDAHO FALLS
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State | ID
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Zip | 83402-2510
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Country | US
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Telephone | 208-681-7182
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Fax |
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Provider Business Mailing Address
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Address Line | 1891 GRANDVIEW CT
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City | IDAHO FALLS
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State | ID
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Zip | 83402-2510
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Country | US
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Telephone | 208-681-7182
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC-4361
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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