MEDICARE: JOHN R THIBODEAU LLC

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	103TC0700X	Clinical Psychologist	PY 7684	FL

General Provider Information

NPI Number	:	1417183419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN R THIBODEAU LLC

Provider Business Mailing Address
First Line	:	296 NEW WATERFORD PL
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-5656
Country	:	US
Telephone Number	:	321-972-5693
Fax Number	:	321-972-5693

Provider Business Practice Location Address
First Line	:	296 NEW WATERFORD PL
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-5656
Country	:	US
Telephone Number	:	321-972-5693
Fax Number	:	321-972-5693

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. JOHN R. THIBODEAU
Credential	:	PH.D.
Telephone Number	:	321-972-5693

Provider Enumeration Date	:	06/04/2009
Last Update Date	:	06/04/2009

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