Provider Demographics
NPI:1467781302
Name:THERIAULT, AMY ELIZABETH
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 19TH ST S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 19TH STREET S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-9990
Practice Address - Country:US
Practice Address - Phone:502-656-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG12163104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker