Provider Demographics
NPI:1487112439
Name:THERIAULT, JUSTIN (DPT)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W234S3555 STATE ROAD 59
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-8512
Mailing Address - Country:US
Mailing Address - Phone:262-532-5820
Mailing Address - Fax:
Practice Address - Street 1:W234S3555 STATE ROAD 59
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-8512
Practice Address - Country:US
Practice Address - Phone:262-532-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14265-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist