Provider Demographics
NPI:1841536885
Name:THERIAULT, CAROLYN (OTR/L)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 E JAMESTOWN RD UNIT 47
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-7309
Mailing Address - Country:US
Mailing Address - Phone:905-766-1038
Mailing Address - Fax:
Practice Address - Street 1:341 E JAMESTOWN RD UNIT 47
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-7309
Practice Address - Country:US
Practice Address - Phone:905-766-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC001517L225X00000X
CA3386225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist