Provider Demographics
NPI:1083910970
Name:THERIAULT, HEATHER ANNA (DC)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ANNA
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1314
Mailing Address - Country:US
Mailing Address - Phone:207-222-2118
Mailing Address - Fax:207-222-2145
Practice Address - Street 1:358 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1314
Practice Address - Country:US
Practice Address - Phone:207-222-2118
Practice Address - Fax:207-222-2145
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR2010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002091902OtherMEDICARE PTAN