Provider Demographics
NPI:1548803646
Name:THERIAULT, TAMMY MARIE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MARIE
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 1:3 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1105
Mailing Address - Country:US
Mailing Address - Phone:850-420-0316
Mailing Address - Fax:
Practice Address - Street 1:3 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1105
Practice Address - Country:US
Practice Address - Phone:850-420-0316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty