MEDICARE: MS. DOROTHY THIBAULT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904001840	VA

General Provider Information

NPI Number	:	1073606075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOROTHY THIBAULT LCSW

Provider Business Mailing Address
First Line	:	2 CARDINAL PARK DR SE
Second Line	:	SUITE 104A
City	:	LEESBURG
State	:	VA
Zip	:	20175-4448
Country	:	US
Telephone Number	:	703-391-8513
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 CARDINAL PARK DR SE
Second Line	:	SUITE 104A
City	:	LEESBURG
State	:	VA
Zip	:	20175-4448
Country	:	US
Telephone Number	:	703-391-8513
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/21/2010

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