Provider Demographics
NPI:1831918325
Name:LEGAULT, THERESA MARIE (OPTICIAN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:LEGAULT
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7494 US HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3577
Mailing Address - Country:US
Mailing Address - Phone:315-268-6921
Mailing Address - Fax:315-268-6923
Practice Address - Street 1:7494 US HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-3577
Practice Address - Country:US
Practice Address - Phone:315-268-3921
Practice Address - Fax:315-268-6923
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC006845-01156FX1800X
NY6845156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician