Provider Demographics
NPI:1073717765
Name:TERRY, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 ELKIN DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2110
Mailing Address - Country:US
Mailing Address - Phone:631-775-6032
Mailing Address - Fax:
Practice Address - Street 1:260 W MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8322
Practice Address - Country:US
Practice Address - Phone:631-647-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0749771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNS5451Medicare ID - Type UnspecifiedEMPIRE