Provider Demographics
NPI:1336697549
Name:TERRELL, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:TERRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:2987 BRINKLEY RD APT 102
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-6009
Mailing Address - Country:US
Mailing Address - Phone:240-470-2039
Mailing Address - Fax:
Practice Address - Street 1:2987 BRINKLEY RD APT 102
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-6009
Practice Address - Country:US
Practice Address - Phone:240-470-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6507101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional