Provider Demographics
NPI:1104968551
Name:THERIAULT, ROBERT THOMAS
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:THOMAS
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 ASHTON OAKS CT
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4408 ASHTON OAKS CT
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-9230
Practice Address - Country:US
Practice Address - Phone:336-880-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1178 LMFT101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional