Provider Demographics
NPI:1134146871
Name:DUSHENKO, TERRANCE W (PHD)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:W
Last Name:DUSHENKO
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 1:1045 ATLANTIC AVE
Mailing Address - Street 2:#806
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813
Mailing Address - Country:US
Mailing Address - Phone:562-590-5594
Mailing Address - Fax:562-590-5596
Practice Address - Street 1:1045 ATLANTIC AVE
Practice Address - Street 2:#806
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-590-5594
Practice Address - Fax:562-590-5596
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8397103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R62295Medicare UPIN
CACP8397Medicare ID - Type Unspecified