Provider Demographics
NPI:1255466488
Name:WRIGHT, TERRY L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 63RD ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1243
Mailing Address - Country:US
Mailing Address - Phone:630-714-5812
Mailing Address - Fax:312-751-6976
Practice Address - Street 1:800 ROOSEVELT RD
Practice Address - Street 2:BLDG. A, STE. 321
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5839
Practice Address - Country:US
Practice Address - Phone:630-714-5812
Practice Address - Fax:312-751-6976
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL217081Medicare ID - Type Unspecified