=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649397928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE EDWARD THERIAULT LSW-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 LOMBARD RD.
-----------------------------------------------------
City | CARIBOU
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04736-0748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-498-2575
-----------------------------------------------------
Fax | 207-492-2410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 COOLIDGE AVE
-----------------------------------------------------
City | CARIBOU
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04736-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-493-1067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LSX8780
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------