MEDICARE: MS. MARIA ERB THIBAULT PT, ATC

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	2251S0007X	Sports Physical Therapist	040-002463	VT
2	2255A2300X	Athletic Trainer	104-0000042	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164492161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIA ERB THIBAULT PT, ATC

Provider Business Mailing Address
First Line	:	80 COLCHESTER AVE
Second Line	:
City	:	BURLINGTON
State	:	VT
Zip	:	05401-1417
Country	:	US
Telephone Number	:	802-657-7990
Fax Number	:	802-859-8935

Provider Business Practice Location Address
First Line	:	80 COLCHESTER AVE
Second Line	:
City	:	BURLINGTON
State	:	VT
Zip	:	05401-1417
Country	:	US
Telephone Number	:	802-657-7990
Fax Number	:	802-859-8935

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

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	06/18/2020

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