Provider Demographics
NPI:1366054215
Name:THERIAULT, WILLIAM JOSEPH (MASSAGE PRACTITIONE)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:MASSAGE PRACTITIONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 HUNTINGTON ST.
Mailing Address - Street 2:#7
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648
Mailing Address - Country:US
Mailing Address - Phone:714-260-8487
Mailing Address - Fax:
Practice Address - Street 1:8840 WARNER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-898-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27601OtherMASSAGE PRACTITIONER