Provider Demographics
NPI:1164588950
Name:TERRY, KAREN MICHELLE (PHD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MICHELLE
Last Name:TERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5979 EAST LIVINGSTON AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-2908
Mailing Address - Country:US
Mailing Address - Phone:614-860-0580
Mailing Address - Fax:614-860-0595
Practice Address - Street 1:5979 EAST LIVINGSTON AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-2908
Practice Address - Country:US
Practice Address - Phone:614-860-0580
Practice Address - Fax:614-860-0595
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2293174Medicaid
OH020534563026OtherCARESOURCE
OH2293174Medicaid
OH020534563026OtherCARESOURCE