Provider Demographics
NPI:1710747290
Name:THERIAULT, HOLLY LYNN
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
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 1:62 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-2420
Mailing Address - Country:US
Mailing Address - Phone:781-385-9211
Mailing Address - Fax:
Practice Address - Street 1:574 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1818
Practice Address - Country:US
Practice Address - Phone:781-335-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist