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Individual
BRENT THERIAULT
Active
Individual
BRENT THERIAULT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC, LAT
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
25MT00245400
NJ
2255A2300X
Athletic Trainer
Primary
RT007713
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
T33690967108945
ATHLETIC TRAINER
NJ
Enumeration date
06/04/2021
Last updated
06/04/2021
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