Provider Demographics
NPI:1063831840
Name:TERO, MARY (CAP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TERO
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 TAMIAMI TRL STE 201
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1064
Mailing Address - Country:US
Mailing Address - Phone:941-249-4354
Mailing Address - Fax:941-249-4356
Practice Address - Street 1:1777 TAMIAMI TRL STE 201
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1064
Practice Address - Country:US
Practice Address - Phone:941-249-4354
Practice Address - Fax:941-249-4356
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5722101YA0400X
FLMH16554101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101843200Medicaid