Provider Demographics
NPI:1336343490
Name:THERIAULT, TIMOTHY M (PT)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 STANLEY FALLS DR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-5049
Mailing Address - Country:US
Mailing Address - Phone:469-487-9890
Mailing Address - Fax:
Practice Address - Street 1:17051 DALLAS PKWY STE 430
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7111
Practice Address - Country:US
Practice Address - Phone:469-248-3962
Practice Address - Fax:469-206-0697
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist