Provider Demographics
NPI:1982002515
Name:THERIAULT, JULIE (MA, NCC, LPCA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:MA, NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 KINGMAN DR
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 RALEIGH ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2227
Practice Address - Country:US
Practice Address - Phone:919-285-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-13
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health