Individual
MYRA THERIAULT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LAC
Contact information
Practice address
4424 NE GLISAN ST, PORTLAND, OR 97213-2331
(503) 477-5167
Mailing address
4424 NE GLISAN ST, PORTLAND, OR 97213-2331
(971) 258-0902
Taxonomy
Speciality
Code
Description
License number
State
171100000X
Acupuncturist
Primary
AC174883
OR
Other
Enumeration date
10/27/2015
Last updated
12/07/2020
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