Provider Demographics
NPI:1285232066
Name:TERRY-SMITH, PHILIP B (PHD, LCPC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:B
Last Name:TERRY-SMITH
Suffix:
Gender:M
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1073
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-1073
Mailing Address - Country:US
Mailing Address - Phone:505-305-0933
Mailing Address - Fax:
Practice Address - Street 1:53 CHAVEZ RD
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-5246
Practice Address - Country:US
Practice Address - Phone:505-305-0933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional