Provider Demographics
NPI:1083266795
Name:BAILEY, TERRI LASHELL
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LASHELL
Last Name:BAILEY
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 1:2400 S RIDGEWOOD AVE STE 32
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3073
Mailing Address - Country:US
Mailing Address - Phone:407-782-7250
Mailing Address - Fax:
Practice Address - Street 1:2400 S RIDGEWOOD AVE STE 32
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3073
Practice Address - Country:US
Practice Address - Phone:407-782-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101YM0800XMedicaid