Provider Demographics
NPI:1952621351
Name:TODD, THERIAULT JEANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:THERIAULT
Middle Name:JEANNE
Last Name:TODD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18446 SANTA ALBERTA CIR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5521
Mailing Address - Country:US
Mailing Address - Phone:714-369-7012
Mailing Address - Fax:714-939-7720
Practice Address - Street 1:9940 TALBERT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-369-7012
Practice Address - Fax:714-939-7720
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14108103TC0700X, 103TC2200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth