Provider Demographics
NPI:1750026860
Name:THERIAULT, JULIE E
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:E
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 1:101 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5662
Mailing Address - Country:US
Mailing Address - Phone:207-754-6804
Mailing Address - Fax:
Practice Address - Street 1:101 EAST AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5662
Practice Address - Country:US
Practice Address - Phone:207-777-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC7863101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)