Provider Demographics
NPI:1598332090
Name:THERIAULT, BRENT (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HAY RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE EGG HARBOR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08087-4106
Mailing Address - Country:US
Mailing Address - Phone:609-350-5998
Mailing Address - Fax:
Practice Address - Street 1:3149 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-2866
Practice Address - Country:US
Practice Address - Phone:609-350-5998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0077132255A2300X
NJ25MT002454002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT33690967108945OtherATHLETIC TRAINER