Provider Demographics
NPI:1548312440
Name:THERIAULT, HEATHER LAVALLEE (OD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LAVALLEE
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489
Mailing Address - Country:US
Mailing Address - Phone:860-628-9937
Mailing Address - Fax:860-621-4911
Practice Address - Street 1:27 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-628-9937
Practice Address - Fax:860-621-4911
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1294950001Medicare NSC
U75730Medicare UPIN