Provider Demographics
NPI:1831422773
Name:THIBODEAU, MELISSA K (DPT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:K
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:K
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:701 N COLONY RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2407
Practice Address - Country:US
Practice Address - Phone:203-294-0449
Practice Address - Fax:203-466-8527
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1831422773Medicaid