MEDICARE: DR. TIMOTHY M THERIAULT PT

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	225100000X	Physical Therapist	1069417	TX

General Provider Information

NPI Number	:	1336343490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY M THERIAULT PT

Provider Business Mailing Address
First Line	:	242 STANLEY FALLS DR
Second Line	:
City	:	ANNA
State	:	TX
Zip	:	75409-5049
Country	:	US
Telephone Number	:	469-487-9890
Fax Number	:

Provider Business Practice Location Address
First Line	:	17051 DALLAS PKWY STE 430
Second Line	:
City	:	ADDISON
State	:	TX
Zip	:	75001-7111
Country	:	US
Telephone Number	:	469-248-3962
Fax Number	:	469-206-0697

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	05/14/2022

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