Provider Demographics
NPI:1619259173
Name:THERIAULT, MARIA A (OTL)
Entity Type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:A
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:THERIAULT
Other - Last Name:POTVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OLT
Mailing Address - Street 1:26 LEDGES CT
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-1851
Mailing Address - Country:US
Mailing Address - Phone:207-713-8426
Mailing Address - Fax:
Practice Address - Street 1:151 N TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-3350
Practice Address - Country:US
Practice Address - Phone:207-753-6414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT 1571225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist