MEDICARE: SHELLEY ALANE THERIAULT LMSW

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	1041C0700X	Clinical Social Worker	MC13939	ME

General Provider Information

NPI Number	:	1740526953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY ALANE THERIAULT LMSW

Provider Business Mailing Address
First Line	:	530 ROUTE 1
Second Line	:
City	:	PEMBROKE
State	:	ME
Zip	:	04666-4425
Country	:	US
Telephone Number	:	207-214-0255
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 KIDS COR
Second Line	:
City	:	MACHIAS
State	:	ME
Zip	:	04654-3328
Country	:	US
Telephone Number	:	207-255-8473
Fax Number	:

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

Provider Enumeration Date	:	12/14/2012
Last Update Date	:	12/14/2012

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