Provider Demographics
NPI:1942613997
Name:THERIAULT, THOMAS RAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAY
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 GARRISON CIR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-2546
Mailing Address - Country:US
Mailing Address - Phone:443-504-5631
Mailing Address - Fax:
Practice Address - Street 1:222 COURTHOUSE CT
Practice Address - Street 2:2D
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-1828
Practice Address - Country:US
Practice Address - Phone:443-692-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05432103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist