Provider Demographics
NPI:1164297677
Name:ROLAND, TERRY (RADT)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:ROLAND
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 GREEN RIVER RD SPC 58
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-8273
Mailing Address - Country:US
Mailing Address - Phone:951-317-3955
Mailing Address - Fax:
Practice Address - Street 1:600 W SANTA ANA BLVD STE 109
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4582
Practice Address - Country:US
Practice Address - Phone:714-667-7926
Practice Address - Fax:714-667-7918
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI527950923101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)