Provider Demographics
NPI:1740558469
Name:THERIAULT, CAM L (LSW-C)
Entity Type:Individual
Prefix:
First Name:CAM
Middle Name:L
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:LSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 MEADOW ROAD
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:ME
Mailing Address - Zip Code:04015
Mailing Address - Country:US
Mailing Address - Phone:207-627-6915
Mailing Address - Fax:207-627-7155
Practice Address - Street 1:899 RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1070
Practice Address - Country:US
Practice Address - Phone:207-871-1200
Practice Address - Fax:207-871-1232
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX13381104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker