=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285589234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON M THERIAULT MT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2026
-----------------------------------------------------
Last Update Date | 03/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7640 N WICKHAM RD STE 121B
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-471-9917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3132 CAUTHEN CREEK DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32934-2933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-604-9491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA108681
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------