Provider Demographics
NPI:1174861306
Name:TERRELL, WYLAN (BA)
Entity Type:Individual
Prefix:
First Name:WYLAN
Middle Name:
Last Name:TERRELL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 S HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0818
Mailing Address - Country:US
Mailing Address - Phone:918-851-2675
Mailing Address - Fax:
Practice Address - Street 1:2713 S HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-0818
Practice Address - Country:US
Practice Address - Phone:918-851-2675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor