Provider Demographics
NPI:1821729187
Name:THERIAQUE, MELISSA DENISE
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DENISE
Last Name:THERIAQUE
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 1:2003 S EASTON RD
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-7100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2649 IPU WAI LN
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-7004
Practice Address - Country:US
Practice Address - Phone:931-538-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-18
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician