Provider Demographics
NPI:1386128668
Name:THERRIAULT, DIANE MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:THERRIAULT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DUCKFORD CIR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1506
Mailing Address - Country:US
Mailing Address - Phone:603-233-2157
Mailing Address - Fax:978-688-7533
Practice Address - Street 1:100 MILK STREET
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-1506
Practice Address - Country:US
Practice Address - Phone:978-686-9900
Practice Address - Fax:978-688-7533
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107468106S00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician