MEDICARE: MR. ROBERT THOMAS THERIAULT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	1178 LMFT	NC

General Provider Information

NPI Number	:	1104968551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT THOMAS THERIAULT

Provider Business Mailing Address
First Line	:	4408 ASHTON OAKS CT
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-9230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4408 ASHTON OAKS CT
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-9230
Country	:	US
Telephone Number	:	336-880-7934
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	07/08/2007

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