Provider Demographics
NPI:1396027736
Name:LOVE, TERRELL
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:LOVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 NE 67TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6715 N. MAY AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116
Practice Address - Country:US
Practice Address - Phone:405-602-4705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK080052233Medicaid