Provider Demographics
NPI:1396202099
Name:TERRY, CASEY (RBT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:TERRY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 AHEAHE PL
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8801
Mailing Address - Country:US
Mailing Address - Phone:612-559-6184
Mailing Address - Fax:
Practice Address - Street 1:443 COPP RD
Practice Address - Street 2:
Practice Address - City:KULA
Practice Address - State:HI
Practice Address - Zip Code:96790-7947
Practice Address - Country:US
Practice Address - Phone:612-559-6184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician