Provider Demographics
NPI:1114952637
Name:PROEGER, TERRY SHANNON (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:SHANNON
Last Name:PROEGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WALLACE AVE
Mailing Address - Street 2:SUITE 382
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-6058
Mailing Address - Country:US
Mailing Address - Phone:941-373-0006
Mailing Address - Fax:941-359-8274
Practice Address - Street 1:100 WALLACE AVE
Practice Address - Street 2:SUITE 382
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-6058
Practice Address - Country:US
Practice Address - Phone:941-373-0006
Practice Address - Fax:941-359-8274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2519103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75065Medicare ID - Type UnspecifiedPROVIDER #