Provider Demographics
NPI:1407349129
Name:ROSS, TERRI LYNNE (CM)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNNE
Last Name:ROSS
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 N HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74126-2780
Mailing Address - Country:US
Mailing Address - Phone:918-955-1416
Mailing Address - Fax:
Practice Address - Street 1:11740 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129
Practice Address - Country:US
Practice Address - Phone:918-437-9495
Practice Address - Fax:918-560-1399
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK171M00000XMedicaid