Provider Demographics
NPI:1740913789
Name:THERIOT, CARLA FAWN (LMT)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:FAWN
Last Name:THERIOT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 ATWOOD CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-4944
Mailing Address - Country:US
Mailing Address - Phone:337-654-2790
Mailing Address - Fax:
Practice Address - Street 1:3320 ATWOOD CREEK CT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-4944
Practice Address - Country:US
Practice Address - Phone:337-654-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT127408225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty