Provider Demographics
NPI:1861272957
Name:THIBODEAU, LISA ANN (MED, MSOT, OTR)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:MED, MSOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-4410
Mailing Address - Country:US
Mailing Address - Phone:617-233-5441
Mailing Address - Fax:
Practice Address - Street 1:399 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1218
Practice Address - Country:US
Practice Address - Phone:617-233-5441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT02214225X00000X
MAOTL14999225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist