Provider Demographics
NPI:1114339504
Name:TERRY, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:308 E 79TH ST APT 10EF
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0998
Mailing Address - Country:US
Mailing Address - Phone:914-548-6388
Mailing Address - Fax:
Practice Address - Street 1:308 E 79TH ST APT 10EF
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0998
Practice Address - Country:US
Practice Address - Phone:914-548-6388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR056116-1102L00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102L00000XOtherBLUE CROSS/BLUE SHIELD
NY102L00000XOtherUNITED HEALTH CARE
NY102L00000XMedicaid
NY102L00000XOtherPRIVATE INSRUANCES
NY102L00000XOtherCIGNA
NY102L00000XOtherBLUE CROSS/BLUE SHIELD
NY102L00000XOtherUNITED HEALTH CARE
NY102L00000XOtherCIGNA