Provider Demographics
NPI:1427784370
Name:THERRIAULT, AMY GRAY (LCMHC-A, BSN, RN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GRAY
Last Name:THERRIAULT
Suffix:
Gender:F
Credentials:LCMHC-A, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 SANDY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-8824
Mailing Address - Country:US
Mailing Address - Phone:252-665-3071
Mailing Address - Fax:
Practice Address - Street 1:340 SANDY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-8824
Practice Address - Country:US
Practice Address - Phone:252-665-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC233656163W00000X
NCA17859101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA17859OtherNORTH CAROLINA BOARD OF LICENSED CLINICAL MENTAL HEALTH COUNSELORS