Provider Demographics
NPI:1447014469
Name:BIBEAULT, JOSEPH (LAC)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:BIBEAULT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 N 25TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1016
Mailing Address - Country:US
Mailing Address - Phone:623-606-8170
Mailing Address - Fax:
Practice Address - Street 1:SHEGOI CLINIC
Practice Address - Street 2:4577 W. PECOS RD.
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339
Practice Address - Country:US
Practice Address - Phone:520-517-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21908101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health