Provider Demographics
NPI:1740526953
Name:THERIAULT, SHELLEY ALANE (LMSW)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ALANE
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:ME
Mailing Address - Zip Code:04666-4425
Mailing Address - Country:US
Mailing Address - Phone:207-214-0255
Mailing Address - Fax:
Practice Address - Street 1:15 KIDS COR
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-3328
Practice Address - Country:US
Practice Address - Phone:207-255-8473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC139391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical